Healthcare strategic management and the resource based view

Barriers to Workforce-Driven Innovation in Healthcare

Healthcare systems are continually developing new ways of delivering care in pursuit of quality improvement, increasing patient and provider satisfaction, and enhancing efficiency. This review measures the barriers to workforce-driven innovation in healthcare, a crucial yet underexamined area of study. Research into workforce-driven innovation in healthcare identifies several key barriers and solutions. Major impediments include a lack of knowledge and resources, as well as financial constraints, which hinder the implementation of innovations. Research findings from different regions enumerate organizational capability, leadership quality, and the adequacy of human resource management as influencing factors for innovation. Poor leadership, lack of inter- and cross-organizational learning, and structural barriers related to inadequate communication and formal forums also hinder progress. In addition, the resistance to change and the inability to engage employees effectively further obstruct innovation efforts. These issues can be addressed through the creation of a supportive innovation environment, enhancing training and development, and improving communication networks. Despite thorough database searches, the emerging nature of this topic has resulted in limited literature, restricting a comprehensive comparison of studies. Future research studies should be longitudinal in design, from diverse geographic contexts, and focus on the effects of emerging technologies to comprehensively understand these barriers and develop effective strategies for overcoming them.

Health System-Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis

BACKGROUND

Living donor kidney transplantation (LDKT) is the best treatment option for patients with kidney failure and offers significant medical and economic advantages for both patients and health systems. Despite this, rates of LDKT in Canada have stagnated and vary significantly across Canadian provinces, the reasons for which are not well understood. Our prior work has suggested that system-level factors may be contributing to these differences. Identifying these factors can help inform system-level interventions to increase LDKT.

OBJECTIVE

Our objective is to generate a systemic interpretation of LDKT delivery across provincial health systems with variable performance. We aim to identify the attributes and processes that facilitate the delivery of LDKT to patients, and those that create barriers and compare these across systems with variable performance. These objectives are contextualized within our broader goal of increasing rates of LDKT in Canada, particularly in lower-performing provinces.

METHODS

This research takes the form of a qualitative comparative case study analysis of 3 provincial health systems in Canada that have high, moderate, and low rates of LDKT performance (the percentage of LDKT to all kidney transplantations performed). Our approach is underpinned by an understanding of health systems as complex adaptive systems that are multilevel and interconnected, and involve nonlinear interactions between people and organizations, operating within a loosely bounded network. Data collection will comprise semistructured interviews, document reviews, and focus groups. Individual case studies will be conducted and analyzed using inductive thematic analysis. Following this, our comparative analysis will operationalize resource-based theory to compare case study data and generate explanations for our research question.

RESULTS

This project was funded from 2020 to 2023. Individual case studies were carried out between November 2020 and August 2022. The comparative case analysis will begin in December 2022 and is expected to conclude in April 2023. Submission of the publication is projected for June 2023.

CONCLUSIONS

By investigating health systems as complex adaptive systems and making comparisons across provinces, this study will identify how health systems can improve the delivery of LDKT to patients with kidney failure. Our resource-based theory framework will provide a granular analysis of the attributes and processes that facilitate or create barriers to LDKT delivery across multiple organizations and levels of practice. Our findings will have practice and policy implications and help inform transferrable competencies and system-level interventions conducive to increasing LDKT.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44172.

Health System–Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis (Preprint).. [DOI: 10.2196/preprints.44172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

Living donor kidney transplantation (LDKT) is the best treatment option for patients with kidney failure and offers significant medical and economic advantages for both patients and health systems. Despite this, rates of LDKT in Canada have stagnated and vary significantly across Canadian provinces, the reasons for which are not well understood. Our prior work has suggested that system-level factors may be contributing to these differences. Identifying these factors can help inform system-level interventions to increase LDKT.

OBJECTIVE

Our objective is to generate a systemic interpretation of LDKT delivery across provincial health systems with variable performance. We aim to identify the attributes and processes that facilitate the delivery of LDKT to patients, and those that create barriers and compare these across systems with variable performance. These objectives are contextualized within our broader goal of increasing rates of LDKT in Canada, particularly in lower-performing provinces.

METHODS

This research takes the form of a qualitative comparative case study analysis of 3 provincial health systems in Canada that have high, moderate, and low rates of LDKT performance (the percentage of LDKT to all kidney transplantations performed). Our approach is underpinned by an understanding of health systems as complex adaptive systems that are multilevel and interconnected, and involve nonlinear interactions between people and organizations, operating within a loosely bounded network. Data collection will comprise semistructured interviews, document reviews, and focus groups. Individual case studies will be conducted and analyzed using inductive thematic analysis. Following this, our comparative analysis will operationalize resource-based theory to compare case study data and generate explanations for our research question.

RESULTS

This project was funded from 2020 to 2023. Individual case studies were carried out between November 2020 and August 2022. The comparative case analysis will begin in December 2022 and is expected to conclude in April 2023. Submission of the publication is projected for June 2023.

CONCLUSIONS

By investigating health systems as complex adaptive systems and making comparisons across provinces, this study will identify how health systems can improve the delivery of LDKT to patients with kidney failure. Our resource-based theory framework will provide a granular analysis of the attributes and processes that facilitate or create barriers to LDKT delivery across multiple organizations and levels of practice. Our findings will have practice and policy implications and help inform transferrable competencies and system-level interventions conducive to increasing LDKT.

INTERNATIONAL REGISTERED REPORT

DERR1-10.2196/44172

[The impact of EBSERH management on the production of Brazilian university hospitals]

This study analyzes the evolution of results related to the production of university hospitals (HUs) in Brazil belonging to the Brazilian Hospital Services Company (EBSERH), emphasizing results achieved before and after joining EBSERH. Monthly data of 16 HUs, obtained from the Hospital Information System (SIH/SUS) and from the National Registry of Health Facilities (CNES), were analyzed, referring to the number of hospital admissions, number of professionals, number of beds, average length of stay, average mortality rate, total approved value of Hospitalization Authorizations (AIHs) and average AIH value. The study uses the simple analysis of interrupted time series (ITS) to analyze the effects of EBSERH management on HUs, assessing the level and trend of HU results before and after joining the EBSERH management. Hospitals, in general, had better results after joining the EBSERH, with a reduction in the average length of stay, an increase in the total number of hospitalizations, increase in work force, and an increase in the total amount approved by SUS. Among the analyzed HUs, the ones that showed the greatest performance improvement were HU/UFS, HULW/UFPB, HUOL/UFRN and HU/UFMA.

Barriers To Strategy Implementation In Turkey's Healthcare Industry: Hospital Manager Perspectives

Although strategy implementation has profound implications for delivering efficient service, it has been largely neglected in the healthcare management literature. This study explores the barriers to effective implementation of strategic plans in healthcare organizations. To achieve this end, empirical data were collected from 185 hospital managers in Turkey using a survey-based methodology. A descriptive analysis was undertaken of the survey responses to determine the most important barriers to strategy implementation. The most significant barriers undermining strategy implementation efforts were found to be: low employee motivation, an exclusive focus on financial performance and lack of consensus among decision makers.

Race to the Top of the Hospital Value-Based Purchasing Program

EXECUTIVE SUMMARY

Medicare's Hospital Valued-Based Purchasing (HVBP) program measures hospitals' total performance score (TPS); its measurement strategies have changed regularly since its rollout in 2013. Because the program influences care delivery, it is important to examine how the policy has changed hospitals' behavior and how it may inform future policies. The purpose of this study was to assess the relationship between hospitals' performance on TPS annually from 2013 to 2018 and organizational characteristics. Using the HVBP TPS from 2013 to 2018 and associated hospital characteristics-hospital size, teaching hospital status, system membership, ownership type, urban/rural location, average percentages of patients from Medicare and Medicaid, operating margins, percentages of inpatient revenue as a proportion of total revenue, and case mix index-we conducted a retrospective cohort study of all U.S. hospitals participating in the HVBP program. Regression and panel analyses found that organizations that were expected to have robust and rigid resources were unable to score in the superior category consistently. In addition, organizations were unable to consistently perform positively over time because of changes in the HVBP program measurement and the required organizational responses. Policymakers should consider the ability of organizations to respond to changes to the HVBP program. Likewise, healthcare managers, particularly those in larger organizations, should seek to remove bureaucracy or allow for greater resource slack to meet these changes.

Rapid Response to Drive COVID-19 Research in a Learning Health Care System: Rationale and Design of the Houston Methodist COVID-19 Surveillance and Outcomes Registry (CURATOR)

BACKGROUND

The COVID-19 pandemic has exacerbated the challenges of meaningful health care digitization. The need for rapid yet validated decision-making requires robust data infrastructure. Organizations with a focus on learning health care (LHC) systems tend to adapt better to rapidly evolving data needs. Few studies have demonstrated a successful implementation of data digitization principles in an LHC context across health care systems during the COVID-19 pandemic.

OBJECTIVE

We share our experience and provide a framework for assembling and organizing multidisciplinary resources, structuring and regulating research needs, and developing a single source of truth (SSoT) for COVID-19 research by applying fundamental principles of health care digitization, in the context of LHC systems across a complex health care organization.

METHODS

Houston Methodist (HM) comprises eight tertiary care hospitals and an expansive primary care network across Greater Houston, Texas. During the early phase of the pandemic, institutional leadership envisioned the need to streamline COVID-19 research and established the retrospective research task force (RRTF). We describe an account of the structure, functioning, and productivity of the RRTF. We further elucidate the technical and structural details of a comprehensive data repository-the HM COVID-19 Surveillance and Outcomes Registry (CURATOR). We particularly highlight how CURATOR conforms to standard health care digitization principles in the LHC context.

RESULTS

The HM COVID-19 RRTF comprises expertise in epidemiology, health systems, clinical domains, data sciences, information technology, and research regulation. The RRTF initially convened in March 2020 to prioritize and streamline COVID-19 observational research; to date, it has reviewed over 60 protocols and made recommendations to the institutional review board (IRB). The RRTF also established the charter for CURATOR, which in itself was IRB-approved in April 2020. CURATOR is a relational structured query language database that is directly populated with data from electronic health records, via largely automated extract, transform, and load procedures. The CURATOR design enables longitudinal tracking of COVID-19 cases and controls before and after COVID-19 testing. CURATOR has been set up following the SSoT principle and is harmonized across other COVID-19 data sources. CURATOR eliminates data silos by leveraging unique and disparate big data sources for COVID-19 research and provides a platform to capitalize on institutional investment in cloud computing. It currently hosts deeply phenotyped sociodemographic, clinical, and outcomes data of approximately 200,000 individuals tested for COVID-19. It supports more than 30 IRB-approved protocols across several clinical domains and has generated numerous publications from its core and associated data sources.

CONCLUSIONS

A data-driven decision-making strategy is paramount to the success of health care organizations. Investment in cross-disciplinary expertise, health care technology, and leadership commitment are key ingredients to foster an LHC system. Such systems can mitigate the effects of ongoing and future health care catastrophes by providing timely and validated decision support.

Internal flexibility in health-care organizations: a value-laden perspective on sustainability

Purpose

This study aims to identify the constituents of internal flexibility in health-care organizations for achieving sustainability. The study incorporates resources-based theory and resource-dependence theory to illustrate how health-care organizations exhibit internal flexibility to redress environmental uncertainties and maximize organizational responsiveness.

Design/methodology/approach

This paper conducts a case study in a health-care organization to explore how health-care organizations acquire several resources for attaining internal flexibility. A survey of health-care professionals was conducted to assess the relationships using partial least squares-structural equation modeling.

Findings

In the present study, the dimensions of internal flexibility in health-care organizations are identified. This study also established internal flexibility as a higher-order factor and explained its underlying aspects as a value-laden perspective on sustainability.

Research limitations/implications

The study was conducted in the public health-care context in India. The framework needs to be tested in another context. The sample size for the study was limited to health-care experts, which could be extended to include the customer’s perspective.

Originality/value

The study contributes to the body of knowledge by identifying the specific dimensions of internal flexibility and explains as a higher-order factor. It enhances the understanding of sustainability from a flexibility perspective of the firm.

Framework on strategic competence performance – a case study of a UK NHS organization

Purpose

Extant literature on strategic environment analysis confirm broad evidence of studies on competences in the context of private sector organizations. Nevertheless, there is a growing interest and evidence of strategic competence in public sector organizations seeking to deliver improved performance. This paper attempts to determine the strategic competences of a National Health Service (NHS) unit for better organizational performance.

Design/methodology/approach

Based on the qualitative analysis of empirical evidence collected in a UK based NHS case study organization, we arrive at a strategic competence performance framework for the health unit using research carried out through interviews with employees and partner organization members.

Findings

By examining a UK-based qualitative case study, the proposed framework puts forward four strategic competence pillars vital for delivering organizational performance and effectively managing the environment of NHS unit's operations. The four strategic competences that are identified to foster NHS unit's performance are strategic leadership, staff engagement, knowledge transfer and partnership working.

Originality/value

The study examines the environment in which a UK based NHS health unit operates and identify the different strategic competences to deliver organizational performance.

Sustained Hospital Performance on Hospital Consumer Assessment of Healthcare Providers and Systems Survey Measures: What Are the Determinants?

EXECUTIVE SUMMARY

This study examines hospital characteristics associated with sustained superior performance on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures. We classified hospitals as sustainers if they remained in the top 25th percentile of overall patient ratings of inpatient experience from 2009 through 2013. We classified hospital characteristics as modifiable or unmodifiable. Modifiable characteristics are operational measures that hospitals can change to improve performance; these characteristics include registered nurse (RN) staffing levels, presence of hospitalists, and level of physician integration. Unmodifiable characteristics are core structural dimensions, such as hospital size and teaching status, that require substantial investment to change, as well as market-level factors such as competition and unemployment rates. Using logistic regression analysis, we found that RN staffing levels, Medicare share of inpatient days, teaching status, and market competition were significant predictors of the likelihood that a given hospital sustained high levels of patient ratings over time (i.e., the likelihood of a hospital being classified as a sustainer). Hospitals with a higher ratio of inpatient days to RN staffing and higher Medicare share of inpatient days had lower odds of being classified as sustainers.

High Medicaid Nursing Homes: Organizational and Market Factors Associated With Financial Performance

High Medicaid nursing homes (85% and higher of Medicaid residents) operate in resource-constrained environments. High Medicaid nursing homes (on average) have lower quality and poorer financial performance. However, there is significant variation in performance among high Medicaid nursing homes. The purpose of this study is to examine the organizational and market factors that may be associated with better financial performance among high Medicaid nursing homes. Data sources included Long-Term Care Focus (LTCFocus), Centers for Medicare and Medicaid Services' (CMS) Medicare Cost Reports, CMS Nursing Home Compare, and the Area Health Resource File (AHRF) for 2009-2015. There were approximately 1108 facilities with high Medicaid per year. The dependent variables are nursing homes operating and total margin. The independent variables included size, chain affiliation, occupancy rate, percent Medicare, market competition, and county socioeconomic status. Control variables included staffing variables, resident quality, for-profit status, acuity index, percent minorities in the facility, percent Medicaid residents, metropolitan area, and Medicare Advantage penetration. Data were analyzed using generalized estimating equations with state and year fixed effects. Results suggest that organizational and market slack resources are associated with performance differentials among high Medicaid nursing homes. Higher financial performing facilities are characterized as having nurse practitioners/physician assistants, more beds, higher occupancy rate, higher Medicare and Medicaid census, and being for-profit and located in less competitive markets. Higher levels of Registered Nurse (RN) skill mix result in lower financial performance in high Medicaid nursing homes. Policy and managerial implications of the study are discussed.

Cascading strategy in a large health system: Bridging gaps in hospital alignment through implementation

Using any number of open system strategic frameworks, the planning process follows a fairly consistent trajectory: formulation, implementation, and evaluation. Most agree that the formulation and evaluation phases are the most straightforward, yet successful implementation remains elusive. If done thoughtfully, taking advantage of a complementary framework suitable for aligning facility-level initiatives with system priorities presents a feasible opportunity for health systems interested in cascading enterprise-wide strategy successfully. This study provides lessons learned from: (a) consulting literature addressing barriers to implementing strategy effectively, and (b) analyzing insights from a participatory action research study designed to overcome impediments to aligning hospital-level initiatives with enterprise-wide goals and objectives. The analysis provides a baseline examination of hospital alignment efforts that underscores best practices and exposes gaps in both process and evaluation. Results suggest specific tools may function to effectively engage internal stakeholders in a cooperative process capable of yielding preferred strategic outcomes, particularly through the implementation and evaluation phases.

Resource Dependency and Hospital Performance in Hospital Value-Based Purchasing

To help influence the health care environment as well as the flow of resources into and out of hospitals, the Centers for Medicare & Medicaid Services has implemented a performance incentive initiative called the Hospital Value-Based Purchasing (HVBP) program. As such, this study utilizes the lens of Resource Dependency Theory to evaluate the effect of the external environment on hospital performance as measured by the HVBP program. This study utilizes data from the 2014 American Hospital Association (AHA) Annual Survey database, 2014 Area Health Resource File (AHRF), the 2014 Medicare Final Rule Standardizing File, and the 2014 Medicare Hospital Compare database. The associations between external environment and hospital performance are assessed through multiple regression analysis. Hospital performance scores in the HVBP program are sensitive to environmental factors; however, not all domains are influenced to the same degree. It would seem that hospitals do not have either the same ability or motivation to make changes in each of the value-based purchasing domains. Ultimately, the findings from this study indicate that environmental forces do play a role in hospitals' performance in the HVBP program.

Shifts in Medicaid and Uninsured Payer Mix at Safety-Net and Non-Safety-Net Hospitals During the Great Recession

EXECUTIVE SUMMARY

There has been ongoing concern regarding the viability of safety-net hospitals (SNHs), which care for vulnerable populations. The authors examined payer mix at SNHs and non-SNHs during a period covering the Great Recession using data from the 2006 to 2012 Healthcare Cost and Utilization Project State Inpatient Databases from 38 states. The number of privately insured stays decreased at both SNHs and non-SNHs. Non-SNHs increasingly served Medicaid-enrolled and uninsured patients; in SNHs, the number of Medicaid stays decreased and uninsured stays remained stable. These study findings suggest that SNHs were losing Medicaid-enrolled patients relative to non-SNHs before the Medicaid expansion under the Affordable Care Act (ACA). Postexpansion, Medicaid stays will likely increase for both SNHs and non-SNHs, but the increase at SNHs may not be as large as expected if competition increases. Because hospital stays with private insurance and Medicaid help SNHs offset uncompensated care, a lower-than-expected increase could affect SNHs' ability to care for the remaining uninsured population. Continued monitoring is needed once post-ACA data become available.

The Role of Assisted Living Capacity on Nursing Home Financial Performance

The rapid growth of the assisted living industry has coincided with decreased levels of nursing home occupancy and financial performance. The purpose of this article is to examine the relationships among assisted living capacity, nursing home occupancy, and nursing home financial performance. In addition, we explore whether the relationship between assisted living capacity and nursing home financial performance is mediated by nursing home occupancy. This research utilized publicly available secondary data, for the state of Florida from 2003 through 2015. General descriptive statistics were used to assess the relationships among financial performance, assisted living capacity, and occupancy. To explore the relationships among financial performance, assisted living capacity and occupancy, and test potential mediation of occupancy, we followed Baron and Kenny's approach and estimated 3 models examining the relationships between (1) assisted living capacity and nursing home financial performance, (2) assisted living capacity and nursing home occupancy, and (3) nursing home occupancy and financial performance after assisted living capacity is included in the model. We used generalized estimating equations, to adjust for repeated measures and to model the above relationships. Year fixed effects control for time trend. The independent variable, assisted living beds, was lagged for 1 year to account for the potential influence on financial performance. The final analytic sample consisted of 7688 nursing home-year observations from 657 unique nursing homes. Our findings suggest that assisted living capacity does have a negative impact on nursing homes' financial performance. Even though, assisted living capacity seems not to significantly decrease nursing home occupancy. The relationship between assisted living capacity and financial performance was not mediated through occupancy. These findings suggest that assisted living communities may not be able to significantly reduce nursing home occupancy; however, the presence of assisted living communities may create additional financial/competitive pressures that result in decreased nursing home financial performance.