Health Care Management Review最新文献

Background: Our understanding of how highly reliable care delivery is brought about remains elusive, in part, because there is limited evidence regarding the organizational practices that enable safety organizing-the behaviors and processes underlying high reliability.

Purpose: Because safety organizing relies on discretionary effort and lowering barriers to sharing expertise and discussing threats to safety and errors, we investigate three pay practices and their effects on information sharing and, in turn, safety organizing. Specifically, we examine average pay level, minimum pay rates, and pay dispersion on nursing units and their relationship with information sharing and safety organizing.

Method: Cross-sectional analyses of survey data from 1,461 registered nurses in 45 nursing units in three Midwestern hospitals on safety organizing linked to administrative data on pay practices from the organization's human resource systems. Pay data and survey responses were aggregated to the nursing unit level. PROCESS and structural equation modeling were used to simultaneously test for direct and indirect effects of pay variables on information sharing and safety organizing.

Results: PROCESS and Mplus path analysis indicated that paying a higher minimum rate in the unit and having lower pay dispersion have indirect, desirable associations with safety organizing through information sharing.

Conclusion: Pay practices can help organizations enhance safety organizing. In particular, higher pay rates for the lowest level nurses and lower pay dispersion among nurses are associated with unit-level information sharing and safety organizing.

Practice implications: Having pay practices associated with lower within-unit variation and higher pay for the lowest paid members of a unit may be viable strategies for greater information sharing and safety organizing.

The alignment of physicians' interests with those of their hospital has garnered considerable interest in recent years, in part because of their central role in health care expenditure and patient outcomes. However, the systematic study of physician-hospital alignment is currently impeded by a lack of construct clarity. This is evidenced by research that conflates the actions intended to create alignment with alignment itself. It is also evidenced by a variety of different definitions, conceptualizations, and measures in the literature, most of which are confounded with constructs that are something other than alignment (e.g., commitment, trust).

Critical theoretical analysis: We draw on agency theory and person-organization fit to define physician-hospital alignment as a physician's perception that their financial incentives, goals, and values and those of their hospital are mutually supporting and reinforcing rather than in conflict with one another.

Advance: To better understand the nature of the construct and to help guide future research, we present an integrative framework grounded in physicians' perceptions.

Practice implication: Our definition and framework set the stage for improved construct validation and more systematic study and management of physician-hospital alignment.

Issue: When frontline employees' voice is not heard and their ideas are not implemented, patient care is negatively impacted, and frontline employees are more likely to experience burnout and less likely to engage in subsequent change efforts.

Critical theoretical analysis: Theory about what happens to voiced ideas during the critical stage after employees voice and before performance outcomes are measured is nascent. We draw on research from organizational behavior, human resource management, and health care management to develop a multilevel model encompassing practices and processes at the individual, team, managerial, and organizational levels that, together, provide a nuanced picture of how voiced ideas reach implementation.

Insight/advance: We offer a multilevel understanding of the practices and processes through which voice leads to implementation; illuminate the importance of thinking temporally about voice to better understand the complex dynamics required for voiced ideas to reach implementation; and highlight factors that help ideas reach implementation, including voicers' personal and interpersonal tactics with colleagues and managers, as well as senior leaders modeling and explaining norms and making voice-related processes and practices transparent.

Practice implications: Our model provides evidence-based strategies for bolstering rejected or ignored ideas, including how voicers (re)articulate ideas, whom they enlist to advance ideas, how they engage peers and managers to improve conditions for intentional experimentation, and how they take advantage of listening structures and other formal mechanisms for voice. Our model also highlights how senior leaders can make change processes and priorities explicit and transparent.

Background and purpose: Distributed leadership has been suggested for describing patterns of influence in collaborative settings where public services are performed across professions and organizations. This study explores how leadership in health quality improvement collaboratives (QICs) is characterized by aligned distributed leadership practices, and how these practices relate with experienced progress and achievements in the quality improvement (QI) work.

Methods: The analysis relied on a qualitative, multicase study of two nationwide Danish QICs. Data consisted of 12 single-person and 21 group interviews with local QI teams and local and regional QIC coordinators (85 informants in total), participant observations of 34 meetings within the QICs, and a collection of documentary material. The collected data were analyzed thematically with NVivo.

Results: Leadership practices in local QI teams are characterized by aligned distributed leadership, with leadership activities being widely distributed based on negotiated, emergent practices regarding the aims, roles, and scope of the QI work. However, local quality coordinators play a pivotal role in driving the QI activities, and hierarchical support from hospital/municipal management is a precondition for the contribution of aligned distributed leadership to experienced progress and QIs.

Practice implications: Emergent distributed leadership should be balanced by thorough consolidation of the practices to provide the best circumstances for robust QI. The active participation of formal managers and local coordinators plays a pivotal role in this consolidation and is decisive for the increased potential for long-term success and sustainability of the QI work, particularly within complex QICs.

Background: Although team-based work is deemed key to improving the quality of national health care systems, adverse events related to teamwork account for up to one third of all incidents. Health care teams are typically multiprofessional and diverse in many aspects, but cultural diversity is one of the most challenging.

Purposes: The objective of this review is to systematically analyze the literature to better understand the impact of cultural diversity in health care teams on team processes as well as team and patient outcomes. This study also explores the conditions that enable or hinder team functioning.

Methodology: Through a systematic integrative literature review, this study builds on the input-process-output-context framework. Multiple searches of the main databases led to identifying 43 relevant articles.

Findings: The results suggest that, when not proactively managed, cultural diversity may have a negative effect on team communication and integration, increasing team conflict and thereby negatively influencing team performance, team climate, and patient safety, both directly and indirectly. Yet, when managed properly and in the presence of engaged and culturally sensitive leadership, cultural training, and open and transparent procedures, cultural diversity in health care teams can be an asset to health care organizations. Analyzing and aggregating these findings into an integrative framework, our study identifies several themes and a research agenda for future studies on culturally diverse health care teams.

Practice implications: Our findings suggest that culturally diverse health care teams experience a number of challenges, pointing to the need for action or structures that enable these teams to perform better, such as emphasizing learning and allowing team members time to get to know each other outside work.

Background: Care coordination is central to accountable care organizations (ACOs), especially in Medicaid where many patients have complex medical and social needs. Little is known about how to best organize care coordination resources in this context, particularly whether to centralize them. We examined how care coordinators' location, management, and colocation of both (within ACO headquarters, practice sites, or other organizations) relate to care quality and coordination.

Methods: We conducted a cross-sectional analysis of surveys administered to a sample of practice sites covering all 17 Medicaid ACOs in Massachusetts ( n = 225, response rate = 64%). We applied controlled, cluster-robust regressions, adjusting the significance threshold for the number of ACO clusters, to assess how clinical information sharing across settings, care quality improvement, knowledge of social service referral, and cross-resource coordination (i.e., the ability of multiple resources to work well together) relate to where care coordinators were physically located and/or managed.

Results: Centralizing care coordinators at ACO headquarters was associated with greater information sharing. Embedding care coordinators in practices was associated with greater care quality improvement. Embedding coordinators at other organizations was associated with less information sharing and care quality improvement. Managing coordinators at practice sites and other organizations were associated with better care quality improvement and cross-resource coordination, respectively. Colocating the two functions showed no significant differences.

Practice implications: Choosing care coordinators' locations may present trade-offs. ACOs may strategically choose embedding care coordinators at practice sites for enhanced care quality versus centralizing them at the ACO to facilitate information sharing.

Background: An important element of value-based health care (VBHC) is interprofessional collaboration in integrated practice units (IPUs) for the delivery of the complete cycle of care. High levels of interprofessional collaboration between clinical and nonclinical staff in IPUs are assumed rather than proven. Factors that may stimulate interprofessional collaboration in the context of VBHC are underresearched.

Purpose: The aim of this study was to examine relational coordination (RC) in VBHC and its antecedents.

Approach: A questionnaire was used to examine the association of both team practices and organizational conditions with interprofessional collaboration in IPUs. Gittell's Relational Coordination Survey was drawn upon to measure interprofessional collaboration by capturing the relational dynamics in coordinated working. The questionnaire also included measures of team practices (team meetings and boundary spanning behavior) and organizational conditions (task interdependence and time constraints).

Results: The number of different professional groups participating in team meetings is positively associated with RC in IPUs. Boundary spanning behavior, task interdependence, and time constraints are not associated with RC.

Conclusions: In IPUs, the diversity within interprofessional team meetings is important for establishing high-quality communication and relationships.

Practice implications: Hospital managers should prioritize facilitating and encouraging shared meetings to enhance RC levels among professional groups in IPUs.

Background: Tobacco screening interventions have demonstrated effectiveness at improving population health, yet many people who want to quit using tobacco lack access to professional assistance. One way to address this gap is to train members of the clinical team as tobacco treatment specialists (TTSs).

Purpose: The purpose of this study was to understand how TTSs have been used across a variety of health care organizations implementing health systems change for tobacco treatment and examine the sustainability of TTSs as a health systems change innovation for tobacco cessation.

Methodology: This study used qualitative interviews ( n = 25) to identify themes related to implementing TTSs as a health systems change innovation and examined these themes within the constructs of the theory of innovation implementation.

Results: Insights about implementing TTSs as an innovation primarily aligned with four theoretical constructs: implementation policies and practices, implementation climate, innovation-values fit, and implementation effectiveness. Specific themes were perceived to facilitate the sustainability of TTSs including team-based TTS efforts, widespread awareness of TTS roles, leadership buy-in, and recognized value of TTS services. Barriers to sustainability included inadequate resources (e.g., time and staff), lack of tracking outcomes, inappropriate referrals, and lack of reimbursement.

Practice implications: Health care organizations planning to implement health systems change for tobacco cessation can encourage committed use of TTSs as an innovation by considering the insights provided in this study. These primarily related to five overarching implementation considerations: staff selection and training, tracking and dissemination of impacts, adequate resources, referrals and workflow, and billing and reimbursement.