Reexamining organizational configurations: an update, validation, and expansion of the taxonomy of health networks and systems

Return to sender: Unraveling the role of structural and social network ties in patient sharing networks

Healthcare is increasingly delivered through networks of organizations. Well-structured patient sharing networks are known to have positive associations with the quality of delivered services. However, the drivers of patient sharing relations are rarely studied explicitly. In line with recent developments in network and integration theorizing, we hypothesize that structural and social network ties between organizations are uniquely associated with a higher number of shared patients. We test these hypotheses using a Bayesian zero-dispersed Poisson regression model within the Additive and Multiplicative Effects Framework based on administrative claims data from 732,122 dermatological patients from the Netherlands in 2017. Our results indicate that 2.6% of all dermatological patients are shared and that the amount of shared patients is significantly associated with structural (i.e. emergency contracts) and social (i.e. shared physicians) ties between organizations, confirming our hypotheses. We also find some evidence that patients are shared with more capable organizations. Our findings highlight the role of relational ties in the way health services are delivered. At the same time, they also raise some potential anti-trust concerns.

Charting a Course: A Research Agenda for Studying the Governance of Health Care Networks

Networked forms of organizing in health care are increasingly viewed as an effective means of addressing "wicked", multifaceted health and societal challenges. This is because networks attempt to address these challenges via collaborative approaches in which diverse stakeholders together define the problem(s) and implement solutions. Consequently, there has been a sharp increase in the number and types of networks used in health care. Despite this growth, our understanding of how these networks are governed has not kept pace. The purpose of this chapter is to chart a research agenda for scholars who are interested in studying health care network governance (i.e., the systems of rules and decision-making within networks), which is of particular importance in deliberate networks between organizations. We do so based on our knowledge of the literature and interviews with subject matter experts, both of which are used to identify core network governance concepts that represent gaps in our current knowledge. Our analysis identified various conceptualizations of networks and of their governance, as well as four primary knowledge gaps: "bread and butter" studies of network governance in health care, the role of single organizations in managing health care networks, governance through the life-cycle stages of health care networks, and governing across the multiple levels of health care networks. We first seek to provide some conceptual clarity around networks and network governance. Subsequently, we describe some of the challenges that researchers may confront while addressing the associated knowledge gaps and potential ways to overcome these challenges.

Advancing Pharmacological Treatments for Opioid Use Disorder (ADaPT-OUD): an Implementation Trial in Eight Veterans Health Administration Facilities

BACKGROUND

Identifying effective strategies to improve access to medication treatments for opioid use disorder (MOUD) is imperative. Within the Veterans Health Administration (VHA), provision of MOUD varies significantly, requiring development and testing of implementation strategies that target facilities with low provision of MOUD.

OBJECTIVE

Determine the effectiveness of external facilitation in increasing the provision of MOUD among VHA facilities with low baseline provision of MOUD compared to matched controls.

DESIGN

Pre-post, block randomized study designed to compare facility-level outcomes in a stratified sample of eligible facilities. Four blocks (two intervention facilities in each) were defined by median splits of both the ratio of patients with OUD receiving MOUD and number of patients with OUD not currently receiving MOUD (i.e., number of actionable patients). Intervention facilities participated in a 12-month implementation intervention.

PARTICIPANTS

VHA facilities in the lowest quartile of MOUD provision (35 facilities), eight of which were randomly assigned to participate in the intervention (two per block) with twenty-seven serving as matched controls by block.

INTERVENTION

External facilitation included assessment of local barriers/facilitators, formation of a local implementation team, a site visit for action planning and training/education, cross-facility quarterly calls, monthly coaching calls, and consultation.

MAIN MEASURES

Pre- to post-change in the facility-level ratio of patients with an OUD diagnosis receiving MOUD compared to control facilities.

KEY RESULTS

Intervention facilities significantly increased the ratio of patients with OUD receiving MOUD from an average of 18% at baseline to 30% 1 year later, with an absolute difference of 12% (95% confidence interval [CI]: 6.6%, 17.0%). The difference in differences between intervention and control facilities was 3.0% (95% CI: - 0.2%. 6.7%). The impact of the intervention varied by block, with smaller, less complex facilities more likely to outperform matched controls.

CONCLUSIONS

Intensive external facilitation improved the adoption of MOUD in most low-performing facilities and may enhance adoption beyond other interventions less tailored to individual facility contexts.

Hospital-based health systems 20 years later: A taxonomy for policy research and analysis

OBJECTIVE

Building on the original taxonomy of hospital-based health systems from 20 years ago, we develop a new taxonomy to inform emerging public policy and practice developments.

DATA SOURCES

The 2016 American Hospital Association's (AHA) Annual Survey; the 2016 IQVIA Healthcare Organizations and Systems (HCOS) database; and the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS).

STUDY DESIGN

Cluster analysis of the 2016 AHA Annual Survey data to derive measures of differentiation, centralization, and integration to create categories or types of hospital-based health systems.

DATA COLLECTION

Principal components factor analysis with varimax rotation generating the factors used in the cluster algorithms.

PRINCIPAL FINDINGS

Among the four cluster types, 54% (N = 202) of systems are decentralized (-0.35) and relatively less differentiated (-0.37); 23% of systems (N = 85) are highly differentiated (1.28) but relatively decentralized (-0.29); 15% (N = 57) are highly centralized (2.04) and highly differentiated (0.65); and approximately 9 percent (N = 33) are least differentiated (-1.35) and most decentralized (-0.64). Despite differences in calculation, the Highly Centralized, Highly Differentiated System Cluster and the Undifferentiated, Decentralized System Cluster were similar to those identified 20 years ago. The other two system clusters contained similarities as well as differences from those 20 years ago. Overall, 82 percent of the systems remain relatively decentralized suggesting they operate largely as holding companies allowing autonomy to individual hospitals operating within the system.

CONCLUSIONS

The new taxonomy of hospital-based health systems bears similarities as well as differences from 20 years ago. Important applications of the taxonomy for addressing current challenges facing the healthcare system, such as the transition to value-based payment models, continued consolidation, and the growing importance of the social determinants of health, are highlighted.

Strategic Differentiation of High-Tech Services in Local Hospital Markets

This study assesses organizational and market factors related to high-tech service differentiation in local hospital markets. The sample includes 1704 nonfederal, general acute hospitals in urban counties in the United States. We relate organizational and market factors in 2011 to service differentiation in 2013, using ordinary least squares regression. Data are compiled from the American Hospital Association Annual Survey of Hospitals, Area Resource File, and Centers for Medicare and Medicaid Services. Results show that hospitals differentiate more services relative to market rivals if they are larger than the rival and if the hospitals are further apart geographically. Hospitals differentiate more services if they are large, teaching, and nonprofit or public and if they face more market competition. Hospitals differentiate fewer services from rivals if they belong to multihospital systems. The findings underscore the pressures that urban hospitals face to offer high-tech services despite the potential of high-tech services to drive hospital costs upward.

Assessing the impact of health system organizational structure on hospital electronic data sharing

Objective

Horizontal consolidation in the hospital industry has gained momentum in the United States despite concerns over rising costs and lower quality. Hospital systems frequently point to potential gains in interoperability and electronic exchange of patient information as consolidation benefits. We sought to assess whether hospitals in different health system structures varied in their interoperable data sharing.

Materials and methods

We created a cross-sectional national hospital sample from the 2014 AHA Annual Survey and 2015 IT Supplement. We combined the existing taxonomy of health system organizational forms and the ONC's functionality-based, technology-agnostic definition of interoperability. We used logistic regression models to assess the relationship between health systems' organizational forms and interoperability engagement, controlling for hospital characteristics.

Results

We found that interoperability engagement varied greatly across hospitals in different health system structures, with facilities in more centralized health systems more likely to be interoperable. Hospitals in one system type, featuring centralized insurance product development but diverse service offerings across member organizations, had significantly higher odds of being engaged in interoperable data sharing in our multivariate regression results.

Discussion

The heterogeneity in health system interoperability engagement indicates that incentives to share data vary greatly across organizational strategies and structures. Our results suggest that horizontal consolidation in the hospital industry may not bring significant gains in interoperability progress unless that consolidation takes a specific business alignment form.

Conclusion

Policymakers should be wary of claims that horizontal consolidation will lead to interoperability gains. Future research should explore the specific mechanisms that lead to greater interoperability in certain health system organizational structures.

Ending TB in Australia: Organizational challenges for regional tuberculosis programs

The World Health Organization's End TB Strategy aims to eliminate tuberculosis (TB) by 2050. Low-burden countries such as Australia are targeted for early elimination (2035), which will require an increase in the intensity and scope of case finding and treatment of people with latent TB infection (LTBI). Because 80 % of TB disease in Australia occurs in metropolitan Sydney (New South Wales) and Melbourne (Victoria), the commitment to move towards elimination has major implications for TB programs in these jurisdictions. We report on a case study analysis that compares and contrasts key attributes of each of these healthcare organizations. Such analysis has important implications for all countries seeking to implement international agreements within local health structures. Differences in the organizational structure, culture and systems of care in NSW and Victoria may facilitate or create barriers to changes in organizational system functions, especially the way in which TB prevention and LTBI treatment is delivered. Ratification of global health treaties and the development of national strategies, alone, is insufficient for realizing the promised outcomes. Even in high income countries, global health agendas such as TB elimination can be complicated by differences in local system structure and funding. As the timelines tighten towards 2035, more work must be done to identify the organizational conditions and service models that will facilitate progress towards TB elimination.

Assessing Trends in Hospital System Structures From 2008 to 2015

BACKGROUND

The Affordable Care Act introduced a major systematic change aimed to promote coordination across the care continuum. Yet, it remains unknown the extent to which hospital system structures have changed following the Affordable Care Act. The structure of hospital systems has important implications for the cost, quality, and accessibility of health services.

OBJECTIVES

To assess trends in the structures of hospital systems.

RESEARCH DESIGN

We aggregated data from the American Hospital Association (AHA) Annual Survey to the system level. Using a panel of hospital systems from 2008 to 2015, we assessed trends in the number of hospital systems, their size, ownership characteristics, geospatial arrangements, and integration with outpatient services.

RESULTS

In the period 2008-2015, there was an increasing percentage of hospitals that were system affiliated as well as growth in the number of hospital systems. A greater percentage of hospital systems that were organized as moderately centralized systems transitioned to centralized systems than to decentralized systems (19.8% vs. 4.7%; P<0.001). In terms of geospatial arrangement, a greater percentage of hub-and-spoke systems moved to a regional design than to national systems (20.0% vs. 8.2%; P<0.05). An increasing trend over time toward greater integration with outpatient services was found in a measure of total system level integration with outpatient services.

CONCLUSIONS

Our findings suggest that hospital systems may be moving toward more regional designs. In addition, the trend of increasing integration offered across hospital systems overall, and as portion of total integration, suggests that systems may be increasing their services along the continuum of care.

Moving regional health services planning and management to a population-based approach: implementation of the Regional Operating Model (ROM) in Victoria, Australia

Various jurisdictions are moving towards population-based approaches to plan and manage healthcare services. The evidence on the implementation of these models remains limited. The aim of this study is to evaluate the effect of a regional operating model (ROM) on internal functioning and stakeholder engagement of a regional office. Semi-structured interviews and focus groups with staff members and stakeholders of the North West Metropolitan Regional office in Victoria, Australia, were conducted. Overall, the ROM was perceived as relevant to staff and stakeholders. However, creating shared objectives and priorities across a range of organisations remained a challenge. Area-based planning and management is seen as simplifying management of contracts; however, reservations were expressed about moving from specialist to more generalist approaches. A clearer articulation of the knowledge, skills and competencies required by staff would further support the implementation of the model. The ROM provides a platform for public services and stakeholders to discuss, negotiate and deliver on shared outcomes at the regional level. It provides an integrated managerial platform to improve service delivery and avoid narrow programmatic approaches.

Impact of Health System Affiliation on Hospital Resource Use Intensity and Quality of Care

OBJECTIVE

To assess the impact of hospital affiliation, centralization, and managed care plan ownership on inpatient cost and quality.

DATA SOURCES

Inpatient discharges from 3,957 community hospitals in 44 states and American Hospital Association Annual Survey data from 2010 to 2012.

STUDY DESIGN

We conducted a retrospective longitudinal regression analysis using hierarchical modeling of discharges clustered within hospitals.

DATA COLLECTION

Detailed discharge data including costs, length of stay, and patient characteristics from the Healthcare Cost and Utilization Project State Inpatient Databases were merged with hospital survey data from the American Hospital Association.

PRINCIPAL FINDINGS

Hospitals affiliated with health systems had a higher cost per discharge and better quality of care compared with independent hospitals. Centralized systems in particular had the highest cost per discharge and longest stays. Independent hospitals with managed care plans had a higher cost per discharge and better quality of care compared with other independent hospitals.

CONCLUSIONS

Increasing prevalence of health systems and hospital managed care ownership may lead to higher quality but are unlikely to reduce hospital discharge costs. Encouraging participation in innovative payment and delivery reform models, such as accountable care organizations, may be more powerful options.

Is the system really the solution? Operating costs in hospital systems

Hospital system formation has recently accelerated. Executives emphasize scale economies that lower operating costs, a claim unsupported in academic research. Do systems achieve lower costs than freestanding facilities, and, if so, which system types? We test hypotheses about the relationship of cost with membership in systems, larger systems, and centralized and local hub-and-spoke systems. We also test whether these relationships have changed over time. Examining 4,000 U.S. hospitals during 1998 to 2010, we find no evidence that system members exhibit lower costs. However, members of smaller systems are lower cost than larger systems, and hospitals in centralized systems are lower cost than everyone else. There is no evidence that the system's spatial configuration is associated with cost, although national system hospitals exhibit higher costs. Finally, these results hold over time. We conclude that while systems in general may not be the solution to lower costs, some types of systems are.

A framework for describing health care delivery organizations and systems

Describing, evaluating, and conducting research on the questions raised by comparative effectiveness research and characterizing care delivery organizations of all kinds, from independent individual provider units to large integrated health systems, has become imperative. Recognizing this challenge, the Delivery Systems Committee, a subgroup of the Agency for Healthcare Research and Quality's Effective Health Care Stakeholders Group, which represents a wide diversity of perspectives on health care, created a draft framework with domains and elements that may be useful in characterizing various sizes and types of care delivery organizations and may contribute to key outcomes of interest. The framework may serve as the door to further studies in areas in which clear definitions and descriptions are lacking.

Effect of hospital referral networks on patient readmissions

Previous studies have shown that referral networks encompass important mechanisms of coordination and integration among hospitals, which enhance numerous organizational-level benefits, such as productivity, efficiency, and quality of care. The present study advances previous research by demonstrating how hospital referral networks influence patient readmissions. Data include 360,697 hospitalization events within a regional community of hospitals in the Italian National Health Service. Multilevel hierarchical regression analysis tests the impacts of referral networks' structural characteristics on patient hospital readmissions. The results demonstrate that organizational centrality in the overall referral network and ego-network density have opposing effects on the likelihood of readmission events within hospitals; greater centrality is negatively associated with readmissions, whereas greater ego-network density increases the likelihood of readmission events. Our findings support the (re)organization of healthcare systems and provide important indications for policymakers and practitioners.

A taxonomy of accountable care organizations for policy and practice

OBJECTIVE

To develop an exploratory taxonomy of Accountable Care Organizations (ACOs) to describe and understand early ACO development and to provide a basis for technical assistance and future evaluation of performance.

DATA SOURCES/STUDY SETTING

Data from the National Survey of Accountable Care Organizations, fielded between October 2012 and May 2013, of 173 Medicare, Medicaid, and commercial payer ACOs.

STUDY DESIGN

Drawing on resource dependence and institutional theory, we develop measures of eight attributes of ACOs such as size, scope of services offered, and the use of performance accountability mechanisms. Data are analyzed using a two-step cluster analysis approach that accounts for both continuous and categorical data.

PRINCIPAL FINDINGS

We identified a reliable and internally valid three-cluster solution: larger, integrated systems that offer a broad scope of services and frequently include one or more postacute facilities; smaller, physician-led practices, centered in primary care, and that possess a relatively high degree of physician performance management; and moderately sized, joint hospital-physician and coalition-led groups that offer a moderately broad scope of services with some involvement of postacute facilities.

CONCLUSIONS

ACOs can be characterized into three distinct clusters. The taxonomy provides a framework for assessing performance, for targeting technical assistance, and for diagnosing potential antitrust violations.

Physiotherapy practice in the private sector: organizational characteristics and models

Background

Even if a large proportion of physiotherapists work in the private sector worldwide, very little is known of the organizations within which they practice. Such knowledge is important to help understand contexts of practice and how they influence the quality of services and patient outcomes. The purpose of this study was to: 1) describe characteristics of organizations where physiotherapists practice in the private sector, and 2) explore the existence of a taxonomy of organizational models.

Methods

This was a cross-sectional quantitative survey of 236 randomly-selected physiotherapists. Participants completed a purpose-designed questionnaire online or by telephone, covering organizational vision, resources, structures and practices. Organizational characteristics were analyzed descriptively, while organizational models were identified by multiple correspondence analyses.

Results

Most organizations were for-profit (93.2%), located in urban areas (91.5%), and within buildings containing multiple businesses/organizations (76.7%). The majority included multiple providers (89.8%) from diverse professions, mainly physiotherapy assistants (68.7%), massage therapists (67.3%) and osteopaths (50.2%). Four organizational models were identified: 1) solo practice, 2) middle-scale multiprovider, 3) large-scale multiprovider and 4) mixed.

Conclusions

The results of this study provide a detailed description of the organizations where physiotherapists practice, and highlight the importance of human resources in differentiating organizational models. Further research examining the influences of these organizational characteristics and models on outcomes such as physiotherapists’ professional practices and patient outcomes are needed.

An empirical typology of private child and family serving agencies

Differences in how services are organized and delivered can contribute significantly to variation in outcomes experienced by children and families. However, few comparative studies identify the strengths and limitations of alternative delivery system configurations. The current study provides the first empirical typology of private agencies involved with the formal child welfare system. Data collected in 2011 from a national sample of private agencies were used to classify agencies into five distinct groups based on internal management capacity, service diversification, integration, and policy advocacy. Findings reveal considerable heterogeneity in the population of private child and family serving agencies. Cross-group comparisons suggest that differences in agencies' strategic and structural characteristics correlated with agency directors' perceptions of different pressures in their external environment. Future research can use this typology to better understand local service systems and the extent to which different agency strategies affect performance and other outcomes. Such information has implications for public agency contracting decisions and could inform system-level assessment and planning of services for children and families.

Regional health care planning: a methodology to cluster facilities using community utilization patterns

Background

Community-based health care planning and regulation necessitates grouping facilities and areal units into regions of similar health care use. Limited research has explored the methodologies used in creating these regions. We offer a new methodology that clusters facilities based on similarities in patient utilization patterns and geographic location. Our case study focused on Hospital Groups in Michigan, the allocation units used for predicting future inpatient hospital bed demand in the state’s Bed Need Methodology. The scientific, practical, and political concerns that were considered throughout the formulation and development of the methodology are detailed.

Methods

The clustering methodology employs a 2-step K-means + Ward’s clustering algorithm to group hospitals. The final number of clusters is selected using a heuristic that integrates both a statistical-based measure of cluster fit and characteristics of the resulting Hospital Groups.

Results

Using recent hospital utilization data, the clustering methodology identified 33 Hospital Groups in Michigan.

Conclusions

Despite being developed within the politically charged climate of Certificate of Need regulation, we have provided an objective, replicable, and sustainable methodology to create Hospital Groups. Because the methodology is built upon theoretically sound principles of clustering analysis and health care service utilization, it is highly transferable across applications and suitable for grouping facilities or areal units.

A taxonomy of state public health preparedness units: an empirical examination of organizational structure

OBJECTIVE

State public health preparedness units (SPHPUs) were developed in response to federal funding to improve response to disasters: a responsibility that had not traditionally been within the purview of public health. The SPHPUs were created within the existing public health organizational structure, and their placement may have implications for how the unit functions, how communication takes place, and ultimately how well the key responsibilities are performed. This study empirically identifies a taxonomy of similarly structured SPHPUs and examines whether this structure is associated with state geographic, demographic, and threat-vulnerability characteristics.

DESIGN

Data representing each SPHPU were extracted from publically available sources, including organizational charts and emergency preparedness plans for 2009. A cross-sectional segmentation analysis was conducted of variables representing structural attributes.

SETTING AND PARTICIPANTS

Fifty state public health departments.

MAIN OUTCOME MEASURES

Variables representing "span of control" and "hierarchal levels" were extracted from organizational charts. Structural "complexity" and "centralization" were extracted from state emergency preparedness documents and other secondary sources.

RESULTS

On average, 6.6 people report to the same manager as the SPHPU director; 2.1 levels separate the SPHPU director from the state health officer; and a mean of 13.5 agencies collaborate with SPHPU during a disaster. Despite considerable variability in how SPHPUs had been structured, results of the cluster and principal component analysis identified 7 similarly structured groups. Neither the taxonomic groups nor the individual variables representing structure were found to be associated with state characteristics, including threat vulnerabilities.

CONCLUSIONS

Our finding supports the hypothesis that SPHPUs are seemingly inadvertently (eg, not strategically) organized. This taxonomy provides the basis for which future research can examine how SPHPU structure relates to performance measures and preparedness strategies.

The changing configuration of hospital systems: centralization, federalization, or fragmentation?

PURPOSE

Research on hospital system organization is dated and cross-sectional. We analyze trends in system structure during 2000-2010 to ascertain whether they have become more centralized or decentralized.

DESIGN/METHODOLOGY/APPROACH

We test hypotheses drawn from organization theory and estimate empirical models to study the structural transitions that systems make between different "clusters" defined by the American Hospital Association.

FINDINGS

There is a clear trend toward system fragmentation during most of this period, with a small recent shift to centralization in some systems. Systems decentralize as they increase their members and geographic dispersion. This is particularly true for systems that span multiple states; it is less true for smaller regional systems and local systems that adopt a hub-and-spoke configuration around a teaching hospital.

RESEARCH LIMITATIONS

Our time series ends in 2010 just as health care reform was implemented. We also rely on a single measure of system centralization.

RESEARCH IMPLICATIONS

Systems that appear to be able to centrally coordinate their services are those that operate in local or regional markets. Larger systems that span several states are likely to decentralize or fragment.

PRACTICAL IMPLICATIONS

System fragmentation may thwart policy aims pursued in health care reform. The potential of Accountable Care Organizations rests on their ability to coordinate multiple providers via centralized governance. Hospitals systems are likely to be central players in many ACOs, but may lack the necessary coherence to effectively play this governance role.

ORIGINALITY/VALUE

Not all hospital systems act in a systemic manner. Those systems that are centralized (and presumably capable of acting in concerted fashion) are in the minority and have declined in prevalence over most of the past decade.

The relationship between baseline Organizational Readiness to Change Assessment subscale scores and implementation of hepatitis prevention services in substance use disorders treatment clinics: a case study

Background

The Organizational Readiness to Change Assessment (ORCA) is a measure of organizational readiness for implementing practice change in healthcare settings that is organized based on the core elements and sub-elements of the Promoting Action on Research Implementation in Health Services (PARIHS) framework. General support for the reliability and factor structure of the ORCA has been reported. However, no published study has examined the utility of the ORCA in a clinical setting. The purpose of the current study was to examine the relationship between baseline ORCA scores and implementation of hepatitis prevention services in substance use disorders (SUD) clinics.

Methods

Nine clinic teams from Veterans Health Administration SUD clinics across the United States participated in a six-month training program to promote evidence-based practices for hepatitis prevention. A representative from each team completed the ORCA evidence and context subscales at baseline.

Results

Eight of nine clinics reported implementation of at least one new hepatitis prevention practice after completing the six-month training program. Clinic teams were categorized by level of implementation-high (n = 4) versus low (n = 5)-based on how many hepatitis prevention practices were integrated into their clinics after completing the training program. High implementation teams had significantly higher scores on the patient experience and leadership culture subscales of the ORCA compared to low implementation teams. While not reaching significance in this small sample, high implementation clinics also had higher scores on the research, clinical experience, staff culture, leadership behavior, and measurement subscales as compared to low implementation clinics.

Conclusions

The results of this study suggest that the ORCA was able to measure differences in organizational factors at baseline between clinics that reported high and low implementation of practice recommendations at follow-up. This supports the use of the ORCA to describe factors related to implementing practice recommendations in clinical settings. Future research utilizing larger sample sizes will be essential to support these preliminary findings.

Understanding the organization of public health delivery systems: an empirical typology

CONTEXT

Policy discussions about improving the U.S. health care system increasingly recognize the need to strengthen its capacities for delivering public health services. A better understanding of how public health delivery systems are organized across the United States is critical to improvement. To facilitate the development of such evidence, this article presents an empirical method of classifying and comparing public health delivery systems based on key elements of their organizational structure.

METHODS

This analysis uses data collected through a national longitudinal survey of local public health agencies serving communities with at least 100,000 residents. The survey measured the availability of twenty core public health activities in local communities and the types of organizations contributing to each activity. Cluster analysis differentiated local delivery systems based on the scope of activities delivered, the range of organizations contributing, and the distribution of effort within the system.

FINDINGS

Public health delivery systems varied widely in organizational structure, but the observed patterns of variation suggested that systems adhere to one of seven distinct configurations. Systems frequently migrated from one configuration to another over time, with an overall trend toward offering a broader scope of services and engaging a wider range of organizations.

CONCLUSIONS

Public health delivery systems exhibit important structural differences that may influence their operations and outcomes. The typology developed through this analysis can facilitate comparative studies to identify which delivery system configurations perform best in which contexts.

Evaluating Service Organization Models: The Relevance and Methodological Challenges of a Configurational Approach

Based on the example of the evaluation of service organization models, this article shows how a configurational approach overcomes the limits of traditional methods which for the most part have studied the individual components of various models considered independently of one another. These traditional methods have led to results (observed effects) that are difficult to interpret. The configurational approach, in contrast, is based on the hypothesis that effects are associated with a set of internally coherent model features that form various configurations. These configurations, like their effects, are context-dependent. We explore the theoretical basis of the configuration approach in order to emphasize its relevance, and discuss the methodological challenges inherent in the application of this approach through an in-depth analysis of the scientific literature. We also propose methodological solutions to these challenges. We illustrate from an example how a configurational approach has been used to evaluate primary care models. Finally, we begin a discussion on the implications of this new evaluation approach for the scientific and decision-making communities.

Relationship of Hospital Organizational Culture to Patient Safety Climate in the Veterans Health Administration

Improving safety climate could enhance patient safety, yet little evidence exists regarding the relationship between hospital characteristics and safety climate. This study assessed the relationship between hospitals' organizational culture and safety climate in Veterans Health Administration (VA) hospitals nationally. Data were collected from a sample of employees in a stratified random sample of 30 VA hospitals over a 6-month period (response rate = 50%; n = 4,625). The Patient Safety Climate in Healthcare Organizations (PSCHO) and the Zammuto and Krakower surveys were used to measure safety climate and organizational culture, respectively. Higher levels of safety climate were significantly associated with higher levels of group and entrepreneurial cultures, while lower levels of safety climate were associated with higher levels of hierarchical culture. Hospitals could use these results to design specific interventions aimed at improving safety climate.

Organizational contexts of primary care approaches for managing problem drinking

Little is known about the organizational contexts associated with different primary care (PC) approaches to managing PC patients with drinking problems. Relying upon the Chronic Care Model and a theoretically based taxonomy of health care systems, we identified organizational factors distinguishing PC practices using PC-based approaches (managed by PC providers, mental health specialists, or jointly with specialty services) versus referral-based management in the Veterans Affairs health care system. Data were obtained from a national survey of 218 PC practices characterizing usual management approaches as well as practices' leadership, delivery system design, information system, and decision support characteristics and from a national survey of substance use disorder specialty programs. PC- and referral-based practices did not differ on the sufficiency of their structural resources, physician staffing, or on the availability of specialty services. However, PC-based practices were found to take more responsibility for managing patients' chronic conditions and had more staff for decision support activities.

Variation in quality of care within health systems

BACKGROUND

Although many hospitals belong to health care systems, little is known about the quality of care provided by those systems, or whether characteristics of health care systems are related to the quality of care patients receive. Dimensions of the quality of care provided in 73 hospital systems were examined using hospital quality data publicly reported by the Centers for Medicare & Medicaid Services (CMS). The hospital systems consisted of six or more acute care hospitals and represented 1,510 hospitals. The study was designed to determine whether these dimensions of system quality could be reliably measured, to describe how systems varied with respect to quality of care, and to explore system characteristics potentially related to care quality.

METHODS

Data were made available by CMS for 19 indicators of care quality for pneumonia, surgical infection prevention, acute myocardial infarction (AMI), and congestive heart failure.

RESULTS

At the system level, reliable measures (alphas > .70) were constructed for each of the four clinical areas, and these measures were combined into a single measure of quality (alpha = .85). Variability in system quality was substantial, ranging from 94% to 70% on the combined quality measure. On the clinical area measures, the smallest range was for AMI (99%-85%), whereas the largest was for surgical infection prevention (95%-54%). System ownership and system centralization were significant predictors of quality, accounting for 30% of variance in the combined quality measure. Geographic region, inclusion of teaching hospitals, and system size were unrelated to quality.

DISCUSSION

Systems vary greatly in terms of quality of care in each of the four clinical areas, with for-profit and more decentralized systems appreciably lower in quality of care. System-level quality measures and data could be used to compare processes within systems and to drive improvement efforts.

Hospital-physician collaboration: landscape of economic integration and impact on clinical integration

CONTEXT

Hospital-physician relationships (HPRs) are an important area of academic research, given their impact on hospitals' financial success. HPRs also are at the center of several federal policy proposals such as gain sharing, bundled payments, and pay-for-performance (P4P).

METHODS

This article analyzes the HPRs that focus on the economic integration of hospitals and physicians and the goals that HPRs are designed to achieve. It then reviews the literature on the impact of HPRs on cost, quality, and clinical integration.

FINDINGS

The goals of the two parties in HPRs overlap only partly, and their primary aim is not reducing cost or improving quality. The evidence base for the impact of many models of economic integration is either weak or nonexistent, with only a few models of economic integration having robust effects. The relationship between economic and clinical integration also is weak and inconsistent. There are several possible reasons for this weak linkage and many barriers to further integration between hospitals and physicians.

CONCLUSIONS

Successful HPRs may require better financial conditions for physicians, internal changes to clinical operations, application of behavioral skills to the management of HPRs, changes in how providers are paid, and systemic changes encompassing several types of integration simultaneously.

Nurse staffing levels: impact of organizational characteristics and registered nurse supply

OBJECTIVE

To assess the impact of nurse supply in the geographic areas surrounding hospitals on staffing levels in hospital units, while taking into account other factors that influence nurse staffing.

DATA SOURCES

Data regarding 279 patient care units, in 47 randomly selected community hospitals located in 11 clusters in the United States, were obtained directly from the hospitals from the U.S. Census report, National Council of State Boards of Nursing, and The Centers for Medicare and Medicaid Services.

STUDY DESIGN

Cross-sectional analyses with linear mixed modeling to control for nesting of units in hospitals were conducted. For each patient care unit, the hours of care per patient day from registered nurses (RNs), LPNs, nursing assistants, and the skill-mix levels were calculated. These measures of staffing were then regressed on type of unit (intensive care, medical/surgical, telemetry/stepdown), unit size, hospital complexity, and RN supply.

PRINCIPAL FINDINGS

RN hours per patient day and RN skill mix were positively related to intensity of patient care, hospital complexity, and the supply of RNs in the geographic area surrounding the hospital. LPN hours, and licensed skill mix were predicted less reliably but appear to be used as substitutes for RNs. Overtime hours increased in areas with a lower RN supply. Vacancy and turnover rates and the use of contract nurses were not affected by nurse supply.

CONCLUSIONS

This study is the first to show that hospital RN staffing levels on both intensive care and nonintensive care units decrease as the supply of RNs in the surrounding geographic area decreases. We also show that LPN hours rise in areas where RN supply is lower. Further research to describe the quality of hospital care in relation to the supply of nurses in the area is needed.

The impact of health system membership on patient safety initiatives

BACKGROUND

Research in configurations and strategic groups has a rich history of revealing performance differences for hospitals and health care systems.

PURPOSES

To assess the relationship between hospital-led health system configurations and the adoption of patient safety practices. In particular, the adoption of computerized physician order entry (CPOE) and intensive care unit physician staffing (IPS) is analyzed.

METHODOLOGY

Analysis of variance was used to detect differences in patient safety measures based on health networks and systems' initial configuration clustering, and regression was used to assess group membership, controlling for hospital-level characteristics. The 2002 American Hospital Association survey and the first 3 years of the Leapfrog Group annual survey (2003-2005) are used for the analyses.

RESULTS

There were significant differences in CPOE and IPS adoption and implementation levels based on health systems' configurations. Centralized physician/insurance health systems and moderately centralized health systems were the highest configurations in terms of CPOE adoption. Group membership was not positively related to the use of IPS relative to hospitals that are not classified using the taxonomy. In fact, there is a significant and negative adoption rate for both patient safety measures in facilities classified in the independent hospital systems category.

CONCLUSION

There are systematic differences in the adoption of CPOE and IPS patient safety measures based on health system configurations. The configuration with an insurance company as part of its structure was more likely than other groups to be adopting CPOE. PRACTITIONER IMPLICATIONS: Given the durability of group membership, the Leapfrog Group and other patient safety initiatives could explicitly target configurations most likely to adopt and implement patient safety programs.

Safety-Net Hospitals

Vulnerable populations, who have difficulty accessing the health care system, primarily receive their medical care from hospitals. Policy makers have struggled to ensure the survival of “safety-net hospitals,” hospitals that provide a disproportionate share of care to these patient populations. The objective of this article is to develop measures to guide analysis and policy for urban safety-net hospitals. The authors developed three safety-net measures: the socioeconomic status of hospital service area, Medicaid intensity, and uncompensated care burden and its market share. Cluster analysis was used to identify break points that distinguish a safety-net hospital from a non-safety-net hospital. The measures developed were stable and independent, but a data-driven binary assignment of hospitals to a “safety-net” category was not supported. These analyses call into question the empirical basis for distinguishing a specific group of hospitals as safety-net hospitals.

Examining the scope of multibusiness health care firms: implications for strategy and financial performance

OBJECTIVE

Use theory and data to examine the scope of corporate strategies for multibusiness health care firms, also known as organized or integrated health care delivery systems.

DATA SOURCES

Data are from the 2000 HIMSS Analytics Annual Survey of integrated health care delivery systems (IHDS), which provides complete information on businesses owned by IHDS.

STUDY DESIGN

Scope defined as the breadth and type of businesses in which a firm chooses to compete is measured across seven separate business areas: (1) health plans, (2) ambulatory, (3) acute, (4) subacute, (5) home health, (6) other related nonpatient care businesses, and (7) external collaborations. Theories on strategy and organizational configurations along with measures of scope and a novel dataset were used to classify 796 firms into five mutually exclusive groups. The bases for classification were two competitive dimensions of scope: (1) breadth of businesses and (2) mix of existing core businesses versus new noncore businesses.

DATA EXTRACTION METHODS

Unit of analysis is the multibusiness health care firm. Sample consists of 796 firms, defined as nonprofit organizations that own two or more direct patient care businesses in two or more separate areas across the health care value chain. Firms were clustered into five mutually exclusive organizational configurations with unique scope characteristics revealing a new taxonomy of corporate strategies.

PRINCIPAL FINDINGS

Analysis of the scope variables revealed five strategic types (along with the number of firms and distinguishing features of each strategy) defined as follows: (1) Core Service Provider (340 firms with the smallest scope providing core set of patient care services), (2) Mission Based (52 firms with the next smallest scope offering core set of services to underserved populations), (3) Contractor (266 firms with medium scope and contracting with physician groups), (4) Health Plan Focus (83 firms with large scope and providing health plans), and (5) Entrepreneur (55 firms with the largest scope offering both a core set of services and investing in a variety of new noncore business opportunities including many for-profit ventures). Significant differences in financial performance among the strategies were found when controlling for payer reimbursement conditions. Specifically, in an unfavorable condition with high Medicaid and low commercial insurance, the Mission Based strategy performs significantly worse while the Entrepreneur strategy performs surprisingly well, in comparison with the other strategies.

CONCLUSIONS

Findings suggest: (a) scope can be used to classify a large number of multibusiness health care firms into a taxonomy representing a small group of distinct corporate strategies, which are recognizable by senior management in the health care industry, (b) no single strategy dominates in performance across different payer profiles, instead there appears to be complementarities or fit between strategy and payer profiles that determines which firms perform well and which do not under different conditions, and (c) senior management of nonprofit health care firms are cross-subsidizing unprofitable patient care through ownership of nonpatient care businesses including for-profit ventures.

A typology of preferences for participation in healthcare decision making

Classifying patients as "active" or "passive" with regard to healthcare decision making is misleading, since patients have different desires for different components of the decision-making process. Distinguishing patients' desired roles is an essential step towards promoting care that respects and responds to individual patients' preferences. We included items on the 2004 Wisconsin Longitudinal Study mail survey measuring preferences for four components of the decision-making process: physician knowledge of patient medical history, physician disclosure of treatment choices, discussion of treatment choices, and selection of treatment choice. We characterized preference types for 5199 older adults using cluster analysis. Ninety-six percent of respondents are represented by four preference types, all of which prefer maximal information exchange with physicians. Fifty-seven percent of respondents wanted to retain personal control over important medical decisions ("autonomists"). Among the autonomists, 81% preferred to discuss treatment choices with their physician. Thirty-nine percent of respondents wanted their physician to make important medical decisions ("delegators"). Among the delegators, 41% preferred to discuss treatment choices. Female gender, higher educational attainment, better self-rated health, fewer prescription medications, and having a shorter duration at a usual place of care predicted a significantly higher probability of the most active involvement in discussing and selecting treatment choices. The overwhelming majority of older adults want to be given treatment options and have their physician know everything about their medical history; however, there are substantial differences in how they want to be involved in discussing and selecting treatments.

Taxonomy of health networks and systems: a reassessment

OBJECTIVE

To assess a widely recognized multihospital system taxonomy.

DATA SOURCES

The original taxonomy was based on American Hospital Association (AHA) Annual Survey Data for the years 1994 and 1995 and a reexamined version, on 1998 AHA data.

STUDY DESIGN

We assess the appropriateness of using data designed to capture local hospital/system interrelationships to develop a taxonomy of multihospital systems. DATA ABSTRACTION METHODS: The original and reexamined taxonomies used dichotomous measures of service availability, physician practice ownership, and managed care offerings.

PRINCIPAL FINDINGS

The data and measures used to formulate the taxonomy are not appropriate for classifying multihospital systems at the company level.

CONCLUSIONS

Taxonomic studies of multihospital systems are very much needed; future taxonomic studies should make clear distinctions between systems at local versus company levels.