Moving organizational theory in health care forward: A discussion with suggestions for critical advancements

In May 2019, scholars in management and organization of health care organizations and systems met. The opening plenary was a moderated discussion with five distinguished scholars who have exemplified pushing the frontier of organizational theory and practice throughout their careers: Ann Barry Flood of Dartmouth College, John Kimberly of the University of Pennsylvania, Anthony (Tony) Kovner of New York University, Stephen (Steve) Shortell of University of California at Berkeley, and Jacqueline (Jackie) Zinn of Temple University. The discussion was moderated by Ingrid Nembhard of the University of Pennsylvania. The goal of the plenary was to provide an opportunity to hear from senior members of the health care management community how they think about organizational behavior and theory, changes that they have observed, research gaps that they see, and lessons for research and practice that they have learned. This article is the transcript of that plenary discussion. It is shared to capture the intellectual history of the field and help surface the critical advancements still needed in organizational theory and practice in health care. The closing remarks of the panelists summarize recommendations for both practice and scholarship in health care organization management.

[Clinical safety and patient oriented care: descriptive study of 113 Spanish hospitals and similarities in other European countries]

OBJECTIVES

This study describes the stage of development of the Spanish acute care hospitals quality improvement systems. It also presents data on their achievement of some specific requirements related to clinical safety and patient oriented care. Additional data from seven other European countries are included, in order to provide a comparative reference for the analysis of results.

MATERIAL AND METHODS

Cross-sectional descriptive study developed in acute care hospitals with more than 100 beds from 8 European countries. Data was gathered using an on-line questionnaire that had more than 500 close questions. In order to validate the responses, a sample of the hospitals that had answered the questionnaire received an evaluation by external assessors.

RESULTS

A total of 113 public and private Spanish hospitals participated in the study, which represented 34% of the total group that met the inclusion criteria. Another 276 hospitals from 7 other countries also answered the questionnaire. The results associated with quality management, clinical safety and patient oriented care from both groups are presented.

CONCLUSIONS

Improvements must be made in those areas where Spanish hospitals have a lower developmental level than the rest of the participating countries: public dissemination of results from external quality assessments, development of some key mechanisms to promote clinical safety and patient involvement in organisational management.

Rural Hospital Patient Safety Systems Implementation in Two States

CONTEXT AND PURPOSE

With heightened attention to medical errors and patient safety, we surveyed Utah and Missouri hospitals to assess the "state of the art" in patient safety systems and identify changes over time. This study examines differences between urban and rural hospitals.

METHODS

Survey of all acute care hospitals in Utah and Missouri at 2 points in time (2002 and 2004). Factor analysis was used to develop 7 latent variables to summarize the data, comparing rural and urban hospitals at each point in time and on change between the 2 survey times.

FINDINGS

On 3 of the 7 latent variables, there was a statistically significant difference between rural and urban hospitals at the first survey, with rural hospitals indicating lower levels of implementation. The differences remained present on 2 of those latent variables at the second survey. In both cases, 1 of those variables was computerized physician order entry (CPOE) systems. Rural hospitals reported more improvement in systems implementation between the 2 survey times, with the difference statistically significant on 1 of the 7 latent variables; the greatest improvement was in implementation of "root cause analysis."

CONCLUSIONS

Adoption of patient safety systems overall is low. Although rates of adoption among rural versus urban hospitals appear lower, most differences are not statistically significant; the gap between rural and urban hospitals relative to quality measures is narrowing. Change in rural and urban hospitals is in the right direction, with the rate of change higher in rural hospitals for many systems.

Governing boards and profound organizational change in hospitals

Over the past decade the importance of governing boards as policy-making setting and oversight units within organizations has increased dramatically. Although this is true for both corporate- and private-sector organizations (Bacon and Brown 1977; Gelman 1988), it is particularly relevant to the health sector. Hospital governing boards, long considered inconsequential in hospital management, have recently become subject to closer scrutiny. The role of governing boards in decisions affecting hospital strategy and hospital performance is once again a topic of some interest in boardrooms and hospital trade journals. Impressive evidence of the renewed interest in governance is provided by the funding of an instructional consortium by the S.K. Kellogg Foundation to help strengthen trusteeship and governing board decision making, and to improve education for health services managers in the area of governance. Members of the consortium include the Hospital Research and Educational Trust, the American Hospital Association, the American College of Healthcare Executives, and the Association for University Programs in Health Administration. Among the activities being undertaken by this consortium is the development of a self-assessment tool/methodology for boards, a bibliography and reference guide on effective governance for practicing trustees, research workshops for faculty in health administration programs, and a teaching guide on governance and trustee leadership. Despite this interest, the question with which we began this article persists. Do governing boards make a difference? In the course of our review of previous work on governance we found that, more often than not, that question has been transformed into: how do boards influence hospital performance? And very often that question has been further narrowed into: which board structure leads to better hospital performance? We have argued for a respecification of the initial question. Rather than pursuing a definition of the maximally performing governing board, we should perhaps shift our focus back to a fuller understanding of board structure and function, and its influence on hospital change. The model developed here combines four essential, and very basic, questions: 1. What are the basic dimensions that underlie structural variation in different types of governing boards? 2. How do these board types influence structural change in hospitals? 3. How is the effect of board influence on change itself likely to change over time as a function of the hospital's general pattern of growth, decline, stability, or instability?(ABSTRACT TRUNCATED AT 400 WORDS)

Organizational control of hospital infrastructure determines the quality of care

Hospital personnel and their performance underlie all hospital facilities and patient services (the hospital infrastructure). Hence, quality patient care is not exclusively in the domain of the medical staff and must be regarded as a comprehensive responsibility of the hospital. Hospitals must establish behavioral quality systems and teach employees not only how to do their job well to meet technical quality standards, but also how to fulfill patient expectations. Critical and life threatening problems are thereon prevented or minimized, and protection of physicians and hospitals from litigation improves as a result. Governing boards must provide a role model and demand excellence of everyone, in order to improve the performance of the hospital infrastructure.

The quality of care is related to death rates: hospital inpatient management of infants with acute gastroenteritis in Jamaica

The quality of care of random samples of about 40 infants admitted with acute gastroenteritis to each of five hospitals in Jamaica was assessed. Low levels of adherence to consensus care criteria appeared to be correlated with high levels of hospital-specific severity standardized mortality ratios X100 (SSMRs); poor adherence, SSMR 127-230; intermediate adherence, SSMR 95; good adherence, SSMR 14. The main deficiencies in care at certain hospitals were: non-weighing of infants, incomplete physical examination, inadequate estimation of fluid requirements, and irregular recording of fluid intake. To improve the effective care of infants with gastroenteritis, a quality assurance program is required.

Twenty years of research on the quality of medical care: 1964-1984

Since 1964 we have built on earlier work, with some refinements, particularly in the formulation of explicit criteria of process and outcome; the detailed standardization of case mix when outcomes signify quality; the prespecification of outcomes for follow-up, when adverse outcomes are only the occasion for later assessment of process; a greater emphasis on more subtle organizational characteristics in the study of structure; and the identification of the separate effects of structural attributes by multivariate analysis. We have also paid more systematic attention to questions of measurement, including the veracity and completeness of the record; the procedures of criteria formulation; and the reliability, validity, and screening efficiency of the criteria. A notable advance is the use of decision analysis to identify optimal strategies of care, including the introduction of patient preferences and monetary cost in the specification of such strategies, and the use of decisional algorithms to portray the criteria of quality.

The determinants of nursing home costs in Nebraska's proprietary nursing homes

In the past few years nursing home care expenditures in Nebraska and the U.S. have been the fastest growing component of total health care expenditures. This rate of increase is particularly alarming in view of the fact that nursing home care is financed primarily by the Medicaid program or direct out-of-pocket payments. In fact, given the cutbacks in federal and state funds for this program, consumers will be forced to allocate a larger share of their income to meet the costs of nursing home care. Although nursing home expenditures have grown at an extremely rapid rate, relatively few empirical studies exist which analyze the cost function of nursing home providers. The purpose of this study is to identify factors which have directly influenced the cost of nursing home care in Nebraska and to evaluate the current Nebraska Medicaid reimbursement system in terms of its impact upon nursing home costs. The study was limited to a sample of 40 nursing homes in Nebraska which represents 42% of the total proprietary nursing homes in the state. The sample was limited to those facilities licensed only as an Intermediate Care Facility--I and they had to be receiving some Medicaid revenue. The data were averaged over the period of 1977-79, but the year of analysis corresponded to 1978. Multiple regression analysis was used to measure the effect of the hypothesized independent variables upon two different measures of cost--the average total cost per patient day and the average variable cost per patient day. In the first regression model 76% of the variance was explained and 71% was explained in the second equation. The results of this analysis are basically consistent with the findings of other studies and indicate that the number of staffing hours, patient mix, facility age, administrator experience and administrative intensity are significant determinants of nursing home costs. The most important finding from a policy perspective is that the current retrospective cost-related Medicaid reimbursement system does not provide incentives for minimizing costs. In fact, the present system encourages administrators to overutilize resources and charge higher prices. Considerable evidence exists which suggests that a prospective system would encourage a more efficient allocation of resources without adversely affecting the quality of care. Given the increase in the state's share of the total Medicaid budget, it would appear that a change to a prospective system is critical in order to maintain the financial accessibility to nursing home care by all Nebraska residents.

Factors related to patients' satisfaction with their medical care

Patient satisfaction has become a frequently researched outcome measure of the quality of health-care delivery. This article reviews research of patient satisfaction after recent, identifiable medical care visits. Results of the reviewed studies are grouped into 13 factors of the medical care setting and of the physicians' competence and relationships to their patients which may be related to patient satisfaction. The factors with the clearest relationship to satisfaction include the accessibility of medical care, the organizational structure of clinics, treatment length, perceived competence of physicians, clarity and retention of physicians' communication to patients, physicians' affiliative behavior, physicians' control, and patients' expectations. Other factors with more complicated or no apparent relationship to satisfaction were mode of payment, clarity of patients' communication to physicians, physicians' personality, patients' sociodemographic characteristics, and patients' health status. The additive and potential interactive effects of these factors are discussed. Additional studies of the interactive aspects of the physician-patient relationship are encouraged, and implications for further research are presented, with emphasis on sampling, measurement, and design issues.

Evaluating the effectiveness of nursing home administrations

There has been little previous research on the determinants of the effectiveness of health care administrators. This research gap pertains to virtually all health care areas but is especially germane to the long-term care field, which has only recently witnessed professional growth in nursing home associations and administrator licensing, education, and ethical behavior. The present study examines the effectiveness of nursing home administrators according to economic criteria (costs and profits per patient per day). Multiple regression analysis was used to determine structure and process variables related to those effectiveness measures. Results indicate that process variable which are controllable by administrators themselves account for the bulk of the variability in nursing home administrator effectiveness.