Health Care Management Review最新文献

Background: The U.S. health care system has seen an increase in hospital-physician integration, with hospitals acquiring increasing numbers of physician practices. This shift has been linked to higher costs without significant improvements in quality.

Purpose: This study sought to identify the characteristics of physicians who transitioned from independent practice to hospital integration.

Methodology/approach: We used physician variables, including quality scores, medical school rankings, years of experience, experience treating socially or medically complex patients, practice style, and location, as well as health care market and county-level variables to understand these determinants using a fixed-effects logistic regression model.

Results: A total of 101,746 physicians representing 66 clinical specialties satisfied our inclusion criteria, of which 3,656 became hospital-integrated between 2018 and 2020. The integrating physicians were generally less experienced, had lower quality scores, and generated less revenue per Medicare patient. Their patients, on average, had higher comorbidity scores, were more likely to be dually eligible, and resided in counties with higher poverty rates.

Conclusion: Our findings indicate that the physicians most likely to become hospital integrated are those facing reimbursement pressures due to a complex case mix and the associated challenges of performing well on the quality metrics. We also found some support for the anticompetitive aspects of hospital-physician integration. Our results suggest that hospitals are integrating with a relatively less experienced physician workforce but one that is perhaps more capable of treating clinically and socioeconomically complex patients.

Practice implications: Hospitals interested in using physician integration strategically to improve care quality should put more emphasis on physician quality. Such an approach has the potential to increase efficiency without sacrificing quality of care.

Background: Clinical care in modern intensive care units (ICUs) combines multidisciplinary expertise and a complex array of technologies. These technologies have clearly advanced the ability of clinicians to do more for patients, yet so much equipment also presents the possibility for cognitive overload.

Purpose: The aim of this study was to investigate clinicians' experiences with and perceptions of technology in ICUs.

Methodology/approach: We analyzed qualitative data from 30 interviews with ICU clinicians and frontline managers within four ICUs.

Results: Our interviews identified three main challenges associated with technology in the ICU: (a) too many technologies and too much data; (b) inconsistent and inaccurate technologies; and (c) not enough integration among technologies, alignment with clinical workflows, and support for clinician identities. To address these challenges, interviewees highlighted mitigation strategies to address both social and technical systems and to achieve joint optimization.

Conclusion: When new technologies are added to the ICU, they have potential both to improve and to disrupt patient care. To successfully implement technologies in the ICU, clinicians' perspectives are crucial. Understanding clinicians' perspectives can help limit the disruptive effects of new technologies, so clinicians can focus their time and attention on providing care to patients.

Practice implications: As technology and data continue to play an increasingly important role in ICU care, everyone involved in the design, development, approval, implementation, and use of technology should work together to apply a sociotechnical systems approach to reduce possible negative effects on clinical care for critically ill patients.

Background: There is increasing recognition that beyond frontline workers' ability to speak up, their feeling heard is also vital, both for improving work processes and reducing burnout. However, little is known about the conditions under which frontline workers feel heard.

Purpose: This inductive qualitative study identifies barriers and facilitators to feeling heard among nurses in hospitals.

Methodology: We conducted in-depth semistructured interviews with registered nurses, nurse managers, and nurse practitioners across four hospitals ( N = 24) in a U.S. health system between July 2021 and March 2022. We coded with the aim of developing new theory, generating initial codes by studying fragments of data (lines and segments), examining and refining codes across transcripts, and finally engaging in focused coding across all data collected.

Findings: Frontline nurses who spoke up confronted two types of challenges that prevented feeling heard: (a) walls, which describe organizational barriers that lead ideas to be rejected outright (e.g., empty solicitation), and (b) voids, which describe organizational gaps that lead ideas to be lost in the system (e.g., structural mazes). We identified categories of responsive practices that promoted feeling heard over walls (boundary framing, unscripting, priority enhancing) and voids (procedural transparency, identifying a navigator). These practices appeared more effective when conducted collectively over time.

Conclusion: Both walls and voids can prevent frontline workers from feeling heard, and these barriers may call for distinct managerial practices to address them. Future efforts to measure responsive practices and explore them in broader samples are needed.

Practice implications: Encouraging responsive practices may help ensure that frontline health care workers feel heard.

Background: Quality improvement collaboratives (QICs) have facilitated cross-organizational knowledge exchange in health care. However, the local implementation of many quality improvement (QI) initiatives continues to fail, signaling a need to better understand the contributing factors. Organizational context, particularly the role of social networks in facilitating or hindering implementation within organizations, remains a potentially critical yet underexplored area to addressing this gap.

Purpose: We took a dynamic process perspective to understand how QI project managers' social networks influence the local implementation of QI initiatives developed through QICs.

Methodology: We explored the case of a QIC by triangulating data from an online survey, semistructured interviews, and archival documents from 10 organizations. We divided implementation into four stages and employed qualitative text analysis to examine the relationship between three characteristics of network structure (degree centrality, network density, and betweenness centrality) and the progress of each QI initiative.

Results: The progress of QI initiatives varied considerably among organizations. The transition between stages was influenced by all three network characteristics to varying degrees, depending on the stage. Project managers whose QI initiatives progressed to advanced stages of implementation had formed ad hoc clusters of colleagues passionate about the initiatives.

Conclusion: Implementing QI initiatives appears to be facilitated by the formation of clusters of supportive individuals within organizations; this formation requires high betweenness centrality and high network density.

Practice implications: Flexibly modifying specific network characteristics depending on the stage of implementation may help project managers advance their QI initiatives, achieving more uniform results from QICs.

Background: Although hospital leaders were already at a high risk for psychological and physical illnesses long before the pandemic, the COVID-19 pandemic exacerbated this situation.

Purpose: Recognizing the crucial role of leaders in organizational crises and building on the conservation of resources theory, our study examines how hospital leaders cope with difficulties that endure over an extended period of time. By using the COVID-19 pandemic as an example for prolonged adversity in hospitals, we provide insight into the different responses to a given adversity and further expand knowledge about the role of time in crisis and for resilience.

Methodology/approach: Qualitative expert interviews were conducted with 44 hospital leaders in Austria between December 2020 and November 2021. For data analysis, we used a hybrid approach, consisting of both deductive and inductive coding.

Results: By extending Bardoel and Drago's (2021) conceptual approach on acceptance and strategic resilience, our empirical study shows that during enduring adversity, hospital leaders use both types of resilience. The choice between them and their suitability depends on both the duration of exposure and severity of the adversity.

Conclusion: Our findings further show that when immediately confronted with adversity, leaders tend to rely on resource-preserving acceptance resilience, whereas when dealing with enduring adversity, leaders are more likely to use resilience-enhancing strategic resilience.

Practical implications: Even though leaders rely on both types of resilience, our findings also imply that if opportunities to build strategic resilience are limited, higher burnout and turnover rates might be the consequence.

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.

Background: Toxic work environments and bullying are rampant in health care organizations. The Joint Commission asserted that bullying is a threat to patient safety, and furthermore, it implied that bullying affects clinician psychological safety. However, after decades of trying to reduce bullying, it persists.

Purpose: The purpose of this study was to determine if system justification (SJ) theory can help explain the persistence of bullying in health care organizations. SJ theory posits that people are motivated to justify the systems with which they are embedded, even if those systems are dysfunctional or unfair.

Method: A cross-sectional survey of health care workers ( n = 302) was used to test a moderated mediation model to examine relations between instrumental work climate perceptions and psychological safety, as mediated by SJ and moderated by experiences of workplace bullying.

Results: Analysis revealed that SJ fully mediated negative relations between instrumental climate and psychological safety; because of SJ the instrumental climate no longer had a direct negative association with psychological safety. Furthermore, bullying was found to play a moderating role in the instrumental climate-SJ relationship.

Conclusion: This study found some support for the role of SJ in perpetuating instrumental workplaces and workplace bullying in health care.

Practice implications: Some scholars have proposed that a focus on disrupting workplace contexts that trigger SJ in workers could help break patterns of behavior that enable toxic work environments and bullying to persist.

Background: Hospitals are often tasked with improving patient care while simultaneously increasing operational efficiency. Although efficiency may be gained by maintaining higher patient volume per nurse (higher workload), high-quality patient care requires low levels of nurse turnover, which might be adversely affected by an increase in workload.

Purpose: Drawing upon job demands-resources theory, we hypothesized that hospital-level workload will predict nurse turnover and that nurse turnover will predict patient mortality, and that registered nurse hiring rates and human resource management practices will moderate (buffer) the positive relationship between nurse workload and nurse turnover, whereas quality care structures will moderate (buffer) the positive relationship between nurse turnover and patient mortality.

Methods: We tested this model utilizing multiple sources of time-lagged data collected from a sample of 156 hospitals in the United States.

Results: Our findings suggest that (a) nurse workload is associated with higher nurse turnover, (b) nurse turnover is positively associated with patient mortality, (c) nurse staffing buffers the workload-turnover relationship as a first-stage moderator, and (d) quality care structures act as a second-stage moderator that mitigates the effects of turnover on mortality.

Conclusions/practice implications: The reduction of nurse turnover and patient mortality requires investments in adequate levels of nurse staffing and implementation of quality care structures.

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.