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Casalino LP, Kariv S, Markovits D, Fisman R, Li J. Physician Altruism and Spending, Hospital Admissions, and Emergency Department Visits. JAMA HEALTH FORUM 2024; 5:e243383. [PMID: 39392639 DOI: 10.1001/jamahealthforum.2024.3383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2024] Open
Abstract
Importance Altruism-putting the patient first-is a fundamental component of physician professionalism. Evidence is lacking about the relationship between physician altruism, care quality, and spending. Objective To determine whether there is a relationship between physician altruism, measures of quality, and spending, hypothesizing that altruistic physicians have better results. Design, Setting, and Participants This cross-sectional study that used a validated economic experiment to measure altruism was carried out between October 2018 and November 2019 using a nationwide sample of US primary care physicians and cardiologists. Altruism data were linked to 2019 Medicare claims and multivariable regressions were used to examine the relationship between altruism and quality and spending measures. Overall, 250 physicians in 43 medical practices that varied in size, location, and ownership, and 7626 Medicare fee-for-service beneficiaries attributed to the physicians were included. The analysis was conducted from April 2022 to August 2024. Exposure Physicians completed a widely used modified dictator-game style web-based experiment; based on their responses, they were categorized as more or less altruistic. Main Measures Potentially preventable hospital admissions, potentially preventable emergency department visits, and Medicare spending. Results In all, 1599 beneficiaries (21%) were attributed to the 45 physicians (18%) categorized as altruistic and 6027 patients were attributed to the 205 physicians not categorized as altruistic. Adjusting for patient, physician, and practice characteristics, patients of altruistic physicians had a lower likelihood of any potentially preventable admission (odds ratio [OR], 0.60; 95% CI, 0.38-0.97; P = .03) and any potentially preventable emergency department visit (OR, 0.64; CI, 0.43-0.94; P = .02). Adjusted spending was 9.26% lower (95% CI, -16.24% to -2.27%; P = .01). Conclusions and Relevance This cross-sectional study found that Medicare patients treated by altruistic physicians had fewer potentially preventable hospitalizations and emergency department visits and lower spending. Policymakers and leaders of hospitals, medical practices, and medical schools may want to consider creating incentives, organizational structures, and cultures that may increase, or at least do not decrease, physician altruism. Further research should seek to identify these and other modifiable factors, such as physician selection and training, that may shape physician altruism. Research could also analyze the relationship between altruism and quality and spending in additional medical practices, specialties, and countries, and use additional measures of quality and of patient experience.
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Affiliation(s)
- Lawrence P Casalino
- Deptartment of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Shachar Kariv
- Department of Economics, University of California, Berkeley
| | | | - Raymond Fisman
- Department of Economics, Boston University, Boston, Massachusetts
| | - Jing Li
- Department of Pharmacy, University of Washington, Seattle
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Cobianchi L, Dal Mas F, Massaro M, Biffl W, Catena F, Coccolini F, Dionigi B, Dionigi P, Di Saverio S, Fugazzola P, Kluger Y, Leppäniemi A, Moore EE, Sartelli M, Velmahos G, Woltz S, Angelos P, Ansaloni L. Diversity and ethics in trauma and acute care surgery teams: results from an international survey. World J Emerg Surg 2022; 17:44. [PMID: 35948947 PMCID: PMC9364511 DOI: 10.1186/s13017-022-00446-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 07/11/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Investigating the context of trauma and acute care surgery, the article aims at understanding the factors that can enhance some ethical aspects, namely the importance of patient consent, the perceptiveness of the ethical role of the trauma leader, and the perceived importance of ethics as an educational subject. METHODS The article employs an international questionnaire promoted by the World Society of Emergency Surgery. RESULTS Through the analysis of 402 fully filled questionnaires by surgeons from 72 different countries, the three main ethical topics are investigated through the lens of gender, membership of an academic or non-academic institution, an official trauma team, and a diverse group. In general terms, results highlight greater attention paid by surgeons belonging to academic institutions, official trauma teams, and diverse groups. CONCLUSIONS Our results underline that some organizational factors (e.g., the fact that the team belongs to a university context or is more diverse) might lead to the development of a higher sensibility on ethical matters. Embracing cultural diversity forces trauma teams to deal with different mindsets. Organizations should, therefore, consider those elements in defining their organizational procedures. LEVEL OF EVIDENCE Trauma and acute care teams work under tremendous pressure and complex circumstances, with their members needing to make ethical decisions quickly. The international survey allowed to shed light on how team assembly decisions might represent an opportunity to coordinate team member actions and increase performance.
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Affiliation(s)
- Lorenzo Cobianchi
- Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Via Alessandro Brambilla, 74, 27100, Pavia, PV, Italy.
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
| | - Maurizio Massaro
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
| | - Walter Biffl
- Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery Departmrnt, Pisa University Hospital Pisa, Pisa, Italy
| | - Beatrice Dionigi
- New York Presbyterian Columbia University Irvine Medical Center, Irvine, NY, USA
| | - Paolo Dionigi
- Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Via Alessandro Brambilla, 74, 27100, Pavia, PV, Italy
| | - Salomone Di Saverio
- ASUR Marche 5, San Benedetto del Tronto General Hospital, San Benedetto del Tronto, Italy
| | - Paola Fugazzola
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | | | - George Velmahos
- Harvard Medical School, Boston, MA, USA
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah Woltz
- Department of Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Peter Angelos
- Department of Surgery and MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL, USA
| | - Luca Ansaloni
- Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Via Alessandro Brambilla, 74, 27100, Pavia, PV, Italy
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
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Goor MVD, Bondarouk T, Bos-Nehles A. People Management in Hospitals: Where Doctors and HR Do (Not?) Meet. Health (London) 2022. [DOI: 10.4236/health.2022.146046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Yamamoto C, Wener P, Ripat J, Woodgate RL. Understanding interprofessional team delivery of patient-centered care: a qualitative secondary analysis. J Interprof Care 2021; 36:202-209. [PMID: 33955306 DOI: 10.1080/13561820.2021.1899146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Primary Care providers are expected to deliver patient-centered care (PCC) within teams; however, PCC tends to be studied within the provider-patient dyad, often to the exclusion of interprofessional team relationships. The purpose of this study was to explore how PCC is understood in the context of inter-provider relationships within Collaborative Mental Health Care teams. Previously collected data formed the basis of a qualitative secondary analysis using constructivist grounded theory. Focus group transcripts from six teams were analyzed using constant comparison. Coding, memoing, and diagramming were used to construct categories and themes. Having worked together over time, these teams developed a shared identity termed the Collective in this analysis. We define this social entity including antecedent conditions, the cultural milieu of the Collective, and provider-perceived outcomes. We further detail how these providers understood PCC as a team-delivered practice including the processes of coming together for a more complete picture, delivering the same message, and managing complexity together. We argue that practice settings supporting relationship development between providers, in addition to with the patient, may be essential to team delivery of PCC.
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Affiliation(s)
- Cynthia Yamamoto
- Department of Occupational Therapy, University of Manitoba, Winnipeg, Canada
| | - Pamela Wener
- Department of Occupational Therapy, University of Manitoba, Winnipeg, Canada
| | - Jacquie Ripat
- Department of Occupational Therapy, University of Manitoba, Winnipeg, Canada
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Reed NJ, Wilson N, Hayes KJ. Identifying contextually relevant improvement measures, illustrated by a case of executive walkrounds. Int J Health Care Qual Assur 2021; ahead-of-print. [PMID: 32304292 DOI: 10.1108/ijhcqa-08-2019-0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE A method to engage salient organisational stakeholders in identifying and ranking measures of healthcare improvement programs is described. The method is illustrated using Executive WalkRounds (EWRs) in a multi-site Australian Health District. DESIGN/METHODOLOGY/APPROACH Subject matter experts (SMEs) conducted document analysis, identified potential EWRs measures, created driver diagrams and then eliminated weak measures. Next, a panel of executives skilled in EWRs ranked and ratified the potential measures using a modified Delphi technique. FINDINGS EWRs measurement selection demonstrated the feasibility of the method. Of the total time to complete the method 79% was contributed by SMEs, 14% by administration personnel and 7% by executives. Document analysis revealed three main EWRs aims. Ten of 28 potential measures were eliminated by the SME review. After repeated Delphi rounds the executive panel achieved consensus (75% cut-off) on seven measures. One outcome, one process and one implementation fidelity metric were selected to measure and monitor the impact of EWRs in the health district. PRACTICAL IMPLICATIONS Perceptions of weak relationships between measures and intended improvements can lead to practitioner scepticism. This work offers a structured method to combine the technical expertise of SMEs with the practical knowledge of healthcare staff in selecting improvement measures. ORIGINALITY/VALUE This research describes and demonstrates a novel method to systematically leverage formal and practical types of expertise to select measures that are strongly linked to local quality improvement goals. The method can be applied in diverse healthcare settings.
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Affiliation(s)
- Nick J Reed
- Healthcare and Hospital Process Improvement, Sydney, Australia
| | - Natalie Wilson
- Transforming Your Experience, South Western Sydney Local Health District, Liverpool, Australia
| | - Kathryn J Hayes
- Griffith Business School, Griffith University, Southport, Australia
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Jun J, Kovner CT, Dickson VV, Stimpfel AW, Rosenfeld P. Does unit culture matter? The association between unit culture and the use of evidence-based practice among hospital nurses. Appl Nurs Res 2020; 53:151251. [PMID: 32451012 DOI: 10.1016/j.apnr.2020.151251] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/18/2020] [Accepted: 03/03/2020] [Indexed: 01/29/2023]
Affiliation(s)
- Jin Jun
- University of Michigan, School of Nursing and the Institute of Healthcare Policy and Innovation, 400 N. Ingalls St, Room 2183, Ann Arbor, MI 48109, United States of America.
| | - Christine T Kovner
- New York University, Rory Meyers College of Nursing, 433 First Ave, Room 644, New York, NY 40010, United States of America.
| | - Victoria Vaughan Dickson
- New York University, Rory Meyers College of Nursing, 433 First Ave, Office 742, New York, NY 10010, United States of America.
| | - Amy Witkoski Stimpfel
- New York University, Rory Meyers College of Nursing, 433 First Avenue, Office 658, New York, NY 10010, United States of America.
| | - Peri Rosenfeld
- NYU Langone Heath, Departments of Nursing, 545 First Avenue GH-SC1-164, New York, NY 10016, United States of America.
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Roosan D, Law AV, Karim M, Roosan M. Improving Team-Based Decision Making Using Data Analytics and Informatics: Protocol for a Collaborative Decision Support Design. JMIR Res Protoc 2019; 8:e16047. [PMID: 31774412 PMCID: PMC6906625 DOI: 10.2196/16047] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/22/2019] [Accepted: 09/23/2019] [Indexed: 01/25/2023] Open
Abstract
Background According to the September 2015 Institute of Medicine report, Improving Diagnosis in Health Care, each of us is likely to experience one diagnostic error in our lifetime, often with devastating consequences. Traditionally, diagnostic decision making has been the sole responsibility of an individual clinician. However, diagnosis involves an interaction among interprofessional team members with different training, skills, cultures, knowledge, and backgrounds. Moreover, diagnostic error is prevalent in the interruption-prone environment, such as the emergency department, where the loss of information may hinder a correct diagnosis. Objective The overall purpose of this protocol is to improve team-based diagnostic decision making by focusing on data analytics and informatics tools that improve collective information management. Methods To achieve this goal, we will identify the factors contributing to failures in team-based diagnostic decision making (aim 1), understand the barriers of using current health information technology tools for team collaboration (aim 2), and develop and evaluate a collaborative decision-making prototype that can improve team-based diagnostic decision making (aim 3). Results Between 2019 to 2020, we are collecting data for this study. The results are anticipated to be published between 2020 and 2021. Conclusions The results from this study can shed light on improving diagnostic decision making by incorporating diagnostics rationale from team members. We believe a positive direction to move forward in solving diagnostic errors is by incorporating all team members, and using informatics. International Registered Report Identifier (IRRID) DERR1-10.2196/16047
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Affiliation(s)
- Don Roosan
- Western University of Health Sciences, College of Pharmacy, Pomona, CA, United States
| | - Anandi V Law
- Western University of Health Sciences, College of Pharmacy, Pomona, CA, United States
| | - Mazharul Karim
- Western University of Health Sciences, College of Pharmacy, Pomona, CA, United States
| | - Moom Roosan
- Chapman University, School of Pharmacy, Irvine, CA, United States
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Walter JK, Schall TE, DeWitt AG, Faerber J, Griffis H, Galligan M, Miller V, Arnold RM, Feudtner C. Interprofessional Team Member Communication Patterns, Teamwork, and Collaboration in Pre-family Meeting Huddles in a Pediatric Cardiac Intensive Care Unit. J Pain Symptom Manage 2019; 58:11-18. [PMID: 31004773 PMCID: PMC6800217 DOI: 10.1016/j.jpainsymman.2019.04.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/10/2019] [Accepted: 04/12/2019] [Indexed: 11/28/2022]
Abstract
CONTEXT Interprofessional teams often develop a care plan before engaging in a family meeting in the pediatric cardiac intensive care unit (CICU)-a process that can affect the course of the family meeting and alter team dynamics but that has not been studied. OBJECTIVES To characterize the types of interactions that interprofessional team members have in pre-family meeting huddles in the pediatric CICU by 1) evaluating the amount of time each team member speaks; 2) assessing team communication and teamwork using standardized instruments; and 3) measuring team members' perceptions of collaboration and satisfaction with decision making. METHODS We conducted a prospective observational study in a pediatric CICU. Subjects were members of the interprofessional team attending preparation meetings before care meetings with families of patients admitted to the CICU for longer than two weeks. We quantitatively coded the amount each team member spoke. We assessed team performance of communication and teamwork using the PACT-Novice tool, and we measured perception of collaboration and satisfaction with decision making using the Collaboration and Satisfaction About Care Decisions questionnaire. RESULTS Physicians spoke for an average of 83.9% of each meeting's duration (SD 7.5%); nonphysicians averaged 9.9% (SD 5.2%). Teamwork behaviors were present and adequately performed as judged by trained observers. Significant differences in physician and nonphysician perceptions of collaboration were found in three of 10 observed meetings. CONCLUSION Interprofessional team members' interactions in team meetings provide important information about team dynamics, revealing potential opportunities for improved collaboration and communication in team meetings and subsequent family meetings.
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Affiliation(s)
- Jennifer K Walter
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Theodore E Schall
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Aaron G DeWitt
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer Faerber
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather Griffis
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Meghan Galligan
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Victoria Miller
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robert M Arnold
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Chris Feudtner
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Fleury MJ, Grenier G, Bamvita JM, Chiocchio F. Variables associated with work performance in multidisciplinary mental health teams. SAGE Open Med 2017; 5:2050312117719093. [PMID: 28839935 PMCID: PMC5548312 DOI: 10.1177/2050312117719093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 06/06/2017] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This study investigates work performance among 79 mental health teams in Quebec (Canada). We hypothesized that work performance was positively associated with the use of standardized clinical tools and clinical approaches, integration strategies, "clan culture," and mental health funding per capita. METHODS Work performance was measured using an adapted version of the Work Role Questionnaire. Variables were organized into four key areas: (1) team attributes, (2) organizational culture, (3) inter-organizational interactions, and (4) external environment. RESULTS Work performance was associated with two types of organizational culture (clan and hierarchy) and with two team attributes (use of standardized clinical tools and approaches). DISCUSSION AND CONCLUSION This study was innovative in identifying associations between work performance and best practices, justifying their implementation. Recommendations are provided to develop organizational cultures promoting a greater focus on the external environment and integration strategies that strengthen external focus, service effectiveness, and innovation.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Mental Health University Institute Research Centre, Montreal, QC, Canada
| | - Guy Grenier
- Douglas Mental Health University Institute Research Centre, Montreal, QC, Canada
| | - Jean-Marie Bamvita
- Douglas Mental Health University Institute Research Centre, Montreal, QC, Canada
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Radwan M, Akbari Sari A, Rashidian A, Takian A, Abou-Dagga S, Elsous A. Influence of organizational culture on provider adherence to the diabetic clinical practice guideline: using the competing values framework in Palestinian Primary Healthcare Centers. Int J Gen Med 2017; 10:239-247. [PMID: 28860840 PMCID: PMC5560570 DOI: 10.2147/ijgm.s140140] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Diabetes mellitus (DM) is a serious chronic disease and an important public health issue. This study aimed to identify the predominant culture within the Palestinian Primary Healthcare Centers of the Ministry of Health (PHC-MoH) and the Primary Healthcare Centers of the United Nations Relief and Works Agency for Palestine Refugees (PHC-UNRWA) by using the competing values framework (CVF) and examining its influence on the adherence to the Clinical Practice Guideline (CPG) for DM. METHODS A cross-sectional design was employed with a census sample of all the Palestinian family doctors and nurses (n=323) who work within 71 PHC clinic. A cross-cultural adaptation framework was followed to develop the Arabic version of the CVF questionnaire. RESULTS The overall adherence level to the diabetic guideline was disappointingly suboptimal (51.5%, p<0.001; 47.3% in the PHC-MoH and 55.5% in the PHC-UNRWA). In the PHC-MoH, the clan/group culture was the most predominant (mean =41.13; standard deviation [SD] =8.92), followed by hierarchical (mean =33.14; SD=5.96), while in the PHC-UNRWA, hierarchical was the prevailing culture (mean =48.43; SD =12.51), followed by clan/group (mean =29.73; SD =8.37). Although a positively significant association between the adherence to CPG and the rational culture and a negatively significant association with the developmental archetype were detected in the PHC-MoH, no significant associations were found in the PHC-UNRWA. CONCLUSION Our study demonstrates that the organizational culture has a marginal influence on the adherence to the diabetic guideline. Future research should preferably mix quantitative and qualitative approaches and explore the use of more sensitive instruments to measure such a complex construct and its effects on guideline adherence in small-sized clinics.
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Affiliation(s)
- Mahmoud Radwan
- Department of Health Management and Economics, School of Public Health, International Campus, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Akbari Sari
- Department of Health Management and Economics, School of Public Health, International Campus, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, International Campus, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Takian
- Department of Health Management and Economics, School of Public Health, International Campus, Tehran University of Medical Sciences, Tehran, Iran
| | - Sanaa Abou-Dagga
- Department of Research Affairs and Graduates Studies, Islamic University of Gaza, Gaza Strip, Palestine
| | - Aymen Elsous
- Department of Health Management and Economics, School of Public Health, International Campus, Tehran University of Medical Sciences, Tehran, Iran
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Effect of Organizational Culture on Patient Access, Care Continuity, and Experience of Primary Care. J Ambul Care Manage 2017; 39:242-52. [PMID: 27232685 DOI: 10.1097/jac.0000000000000116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study examined relationships between organizational culture and patient-centered outcomes in primary care. Generalized least squares regression was used to analyze patient access, care continuity, and reported experiences of care among 357 physicians in 41 primary care departments. Compared with a "Group-oriented" culture, a "Rational" culture type was associated with longer appointment wait times, and both "Hierarchical" and "Developmental" culture types were associated with less care continuity, but better patient experiences with care. Understanding the unique effects of organizational culture can enhance the delivery of more patient-centered care.
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Abstract
Purpose
– The purpose of this paper is to explore how leadership is practiced across four different hospital units.
Design/methodology/approach
– The study is a comparative case study of four hospital units, based on detailed observations of the everyday work practices, interactions and interviews with ten interdisciplinary clinical managers.
Findings
– Comparing leadership as configurations of practices across four different clinical settings, the author shows how flexible and often shared leadership practices were embedded in and central to the core clinical work in all units studied here, especially in more unpredictable work settings. Practices of symbolic work and emotional support to staff were particularly important when patients were severely ill.
Research limitations/implications
– Based on a study conducted with qualitative methods, these results cannot be expected to apply in all clinical settings. Future research is invited to extend the findings presented here by exploring leadership practices from a micro-level perspective in additional health care contexts: particularly the embedded and emergent nature of such practices.
Practical implications
– This paper shows leadership practices to be primarily embedded in the clinical work and often shared across organizational or professional boundaries.
Originality/value
– This paper demonstrated how leadership practices are embedded in the everyday work in hospital units. Moreover, the analysis shows how configurations of leadership practices varied in four different clinical settings, thus contributing with contextual accounts of leadership as practice, and suggested “configurations of practice” as a way to carve out similarities and differences in leadership practices across settings.
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Dickinson LM, Dickinson WP, Nutting PA, Fisher L, Harbrecht M, Crabtree BF, Glasgow RE, West DR. Practice context affects efforts to improve diabetes care for primary care patients: a pragmatic cluster randomized trial. J Gen Intern Med 2015; 30:476-82. [PMID: 25472509 PMCID: PMC4370994 DOI: 10.1007/s11606-014-3131-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 10/23/2014] [Accepted: 11/12/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND Efforts to improve primary care diabetes management have assessed strategies across heterogeneous groups of patients and practices. However, there is substantial variability in how well practices implement interventions and achieve desired outcomes. OBJECTIVE To examine practice contextual features that moderate intervention effectiveness. DESIGN Secondary analysis of data from a cluster randomized trial of three approaches for implementing the Chronic Care Model to improve diabetes care. PARTICIPANTS Forty small to mid-sized primary care practices participated, with 522 clinician and staff member surveys. Outcomes were assessed for 822 established patients with a diagnosis of type 2 diabetes who had at least one visit to the practice in the 18 months following enrollment. MAIN MEASURES The primary outcome was a composite measure of diabetes process of care, ascertained by chart audit, regarding nine quality measures from the American Diabetes Association Physician Recognition Program: HgA1c, foot exam, blood pressure, dilated eye exam, cholesterol, nephropathy screen, flu shot, nutrition counseling, and self-management support. Data from practices included structural and demographic characteristics and Practice Culture Assessment survey subscales (Change Culture, Work Culture, Chaos). KEY RESULTS Across the three implementation approaches, demographic/structural characteristics (rural vs. urban + .70(p = .006), +2.44(p < .001), -.75(p = .004)); Medicaid: < 20 % vs. ≥ 20 % (-.20(p = .48), +.75 (p = .08), +.60(p = .02)); practice size: < 4 clinicians vs. ≥ 4 clinicians (+.56(p = .02), +1.96(p < .001), +.02(p = .91)); practice Change Culture (high vs. low: -.86(p = .048), +1.71(p = .005), +.34(p = .22)), Work Culture (high vs. low: -.67(p = .18), +2.41(p < .001), +.67(p = .005)) and variability in practice Change Culture (high vs. low: -.24(p = .006), -.20(p = .0771), -.44(p = .0019) and Work Culture (high vs. low: +.56(p = .3160), -1.0(p = .008), -.25 (p = .0216) were associated with trajectories of change in diabetes process of care, either directly or differentially by study arm. CONCLUSIONS This study supports the need for broader use of methodological approaches to better examine contextual effects on implementation and effectiveness of quality improvement interventions in primary care settings.
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Affiliation(s)
- L Miriam Dickinson
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA,
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Psek WA, Stametz RA, Bailey-Davis LD, Davis D, Darer J, Faucett WA, Henninger DL, Sellers DC, Gerrity G. Operationalizing the learning health care system in an integrated delivery system. EGEMS 2015; 3:1122. [PMID: 25992388 PMCID: PMC4434917 DOI: 10.13063/2327-9214.1122] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Introduction: The Learning Health Care System (LHCS) model seeks to utilize sophisticated technologies and competencies to integrate clinical operations, research and patient participation in order to continuously generate knowledge, improve care, and deliver value. Transitioning from concept to practical application of an LHCS presents many challenges but can yield opportunities for continuous improvement. There is limited literature and practical experience available in operationalizing the LHCS in the context of an integrated health system. At Geisinger Health System (GHS) a multi-stakeholder group is undertaking to enhance organizational learning and develop a plan for operationalizing the LHCS system-wide. We present a framework for operationalizing continuous learning across an integrated delivery system and lessons learned through the ongoing planning process. Framework: The framework focuses attention on nine key LHCS operational components: Data and Analytics; People and Partnerships; Patient and Family Engagement; Ethics and Oversight; Evaluation and Methodology; Funding; Organization; Prioritization; and Deliverables. Definitions, key elements and examples for each are presented. The framework is purposefully broad for application across different organizational contexts. Conclusion: A realistic assessment of the culture, resources and capabilities of the organization related to learning is critical to defining the scope of operationalization. Engaging patients in clinical care and discovery, including quality improvement and comparative effectiveness research, requires a defensible ethical framework that undergirds a system of strong but flexible oversight. Leadership support is imperative for advancement of the LHCS model. Findings from our ongoing work within the proposed framework may inform other organizations considering a transition to an LHCS.
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Abstract
BACKGROUND Organizational culture is key to the successful implementation of major improvement strategies. Transformation to a patient-centered medical home (PCHM) is such an improvement strategy, requiring a shift from provider-centric care to team-based care. Because this shift may impact provider satisfaction, it is important to understand the relationship between provider satisfaction and organizational culture, specifically in the context of practices that have transformed to a PCMH model. METHODS This was a cross-sectional study of surveys conducted in 2011 among providers and staff in 10 primary care clinics implementing their version of a PCMH: Care by Design. Measures included the Organizational Culture Assessment Instrument and the American Medical Group Association provider satisfaction survey. RESULTS Providers were most satisfied with quality of care (mean, 4.14; scale of 1-5) and interactions with patients (mean, 4.12) and were least satisfied with time spent working (mean, 3.47), paperwork (mean, 3.45), and compensation (mean, 3.35). Culture profiles differed across clinics, with family/clan and hierarchical cultures the most common. Significant correlations (P ≤ .05) between provider satisfaction and clinic culture archetypes included family/clan culture negatively correlated with administrative work; entrepreneurial culture positively correlated with the Time Spent Working dimension; market/rational culture positively correlated with how practices were facing economic and strategic challenges; and hierarchical culture negatively correlated with the Relationships with Staff and Resource dimensions. CONCLUSIONS Provider satisfaction is an important metric for assessing experiences with features of a PCMH model. Identification of clinic-specific culture archetypes and archetype associations with provider satisfaction can help inform practice redesign. Attention to effective methods for changing organizational culture is recommended.
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Dickinson WP, Dickinson LM, Nutting PA, Emsermann CB, Tutt B, Crabtree BF, Fisher L, Harbrecht M, Gottsman A, West DR. Practice facilitation to improve diabetes care in primary care: a report from the EPIC randomized clinical trial. Ann Fam Med 2014; 12:8-16. [PMID: 24445098 PMCID: PMC3896533 DOI: 10.1370/afm.1591] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation. METHODS We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys. RESULTS Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices. CONCLUSIONS Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.
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Affiliation(s)
- W Perry Dickinson
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Lewis S, Bloom J, Rice J, Naeim A, Shortell S. Using teams to implement personalized health care across a multi-site breast cancer network. Adv Health Care Manag 2014; 16:71-94. [PMID: 25626200 DOI: 10.1108/s1474-823120140000016004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE This study sought to identify the organizational factors associated with team and network effectiveness of the Athena Breast Health Network, a multi-site collaboration between five University of California health systems. DESIGN/METHODOLOGY/APPROACH Providers, managers, and support staff completed self-administered surveys over three years. Statistical analyses at the network and medical center levels tested hypotheses regarding the correlates of effective teams and perceived network effectiveness over time. FINDINGS Perceived team effectiveness was positively correlated with group culture and environments which support collaboration, negatively correlated with hierarchical culture, and negatively associated with professional tenure at year two. As measured by increasing team effectiveness scores over time and Athena's potential impact on patient care, perceived network effectiveness was positively associated with team effectiveness. RESEARCH LIMITATIONS/IMPLICATIONS Results do not allow us to conclude that a certain type of culture "causes" team effectiveness or that team effectiveness "causes" greater perceptions of progress over time. Subsequent studies should examine these variables simultaneously. Further research is needed to examine the role of payment incentives, internal reward systems, the use of electronic health records, public disclosure of performance data, and depth of leadership within each organization and within the network overall. PRACTICAL IMPLICATIONS - Focusing on group affiliation and participation may improve team member perceptions regarding effectiveness and impact on patient care. ORIGINALITY/VALUE Relatively little is known about the adaptive processes that occur within inter-organizational networks to achieve desired goals, and particularly the roles played by multi-disciplinary interprofessional teams. We studied a network comprising multiple campuses actively involved in better understanding, preventing, and treating a complex disease.
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Klabunde CN, Willis GB, Casalino LP. Facilitators and Barriers to Survey Participation by Physicians. Eval Health Prof 2013; 36:279-95. [DOI: 10.1177/0163278713496426] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Surveys of health care providers are a well-established tool for obtaining information about the organization and delivery of care as well as about provider knowledge and attitudes. However, declining response rates to provider surveys are a widely acknowledged concern. Although a number of studies have identified specific methods for increasing response rates in health care provider—and particularly physician—surveys, few have addressed the more fundamental question of what motivates or deters providers from survey participation. We briefly review theoretical perspectives concerning why providers choose to participate in surveys, and what is known about facilitators and barriers to participation. We then describe several research designs (i.e., focus groups, key informant interviews, diary and office workflow studies, surveying the surveyors, and follow-back studies of respondents/nonrespondents) for obtaining empirical data on facilitators and barriers to survey participation, particularly by physicians and medical groups. Researchers must begin to build an evidence base for understanding provider decisions concerning survey participation.
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Affiliation(s)
- Carrie N. Klabunde
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Gordon B. Willis
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Lawrence P. Casalino
- Department of Public Health, Division of Outcomes and Effectiveness Research, Weill Cornell Medical College, New York, NY, USA
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McClellan SR, Casalino LP, Shortell SM, Rittenhouse DR. When does adoption of health information technology by physician practices lead to use by physicians within the practice? J Am Med Inform Assoc 2013; 20:e26-32. [PMID: 23396512 DOI: 10.1136/amiajnl-2012-001271] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We sought to determine the extent to which adoption of health information technology (HIT) by physician practices may differ from the extent of use by individual physicians, and to examine factors associated with adoption and use. MATERIALS AND METHODS Using cross-sectional survey data from the National Study of Small and Medium-Sized Physician Practices (July 2007-March 2009), we examined the extent to which organizational capabilities and external incentives were associated with the adoption of five key HIT functionalities by physician practices and with use of those functionalities by individual physicians. RESULTS The rate of physician practices adopting any of the five HIT functionalities was 34.1%. When practices adopted HIT functionalities, on average, about one in seven physicians did not use those functionalities. One physician in five did not use prompts and reminders following adoption by their practice. After controlling for other factors, both adoption of HIT by practices and use of HIT by individual physicians were higher in primary care practices and larger practices. Practices reporting an emphasis on patient-centered management were not more likely than others to adopt, but their physicians were more likely to use HIT. DISCUSSION Larger practices were most likely to have adopted HIT, but other factors, including specialty mix and self-reported patient-centered management, had a stronger influence on the use of HIT once adopted. CONCLUSIONS Adoption of HIT by practices does not mean that physicians will use the HIT.
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Affiliation(s)
- Sean R McClellan
- Health Services and Policy Analysis Program, University of California, Berkeley, California 94720, USA.
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Tanenbaum SJ. Reducing variation in health care: the rhetorical politics of a policy idea. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2013; 38:5-26. [PMID: 23052690 DOI: 10.1215/03616878-1898774] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
For decades, geographic variation in the use and cost of health care has captured the imagination of researchers and policy makers. As a policy problem, variation suggests its own solution--reducing variation--but the substantive weaknesses of this policy idea invite a second look at its success. This article considers the politics of policy ideas to analyze the potential rhetorical strengths of reducing variation. It finds that this idea appeals to multiple health care audiences, remains practically and politically ambiguous as to problem and solution, and resonates with long-held aspirations of policy elites, including being hopeful about solving the seemingly intractable problems of the US health care system.
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