Health Care Management Review最新文献

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.

Background: Whereas organizational literature has provided much insight into the conceptual and theoretical underpinnings of organizational leadership and management during emergencies, measures to operationalize related effective practices during crises remain sparse.

Purpose: To address this need, we developed the Healthcare Emergency Response Optimization survey, which set out to examine the leadership and management practices in health care organizations that support resilience and performance during crisis.

Methodology: We administered an online survey in April to May 2022 to health care administrators and frontline staff intimately involved in their hospital's emergency response during the COVID-19 pandemic, which included a sample of 379 respondents across nine rural and urban hospitals (response rate: 44.4%). We used confirmatory factor analysis and quantile regressions to examine the results.

Results: Applying confirmatory factor analysis, we retained 36 items in our survey that comprised eight measures for formal and informal practices to assess crisis leadership and management. To test effectiveness of the specified practices, we regressed self-reported resilience and performance measures on the formality and informality scores. Findings show that informal practices mattered most for resilience, whereas formal practices mattered most for performance. We also identified specific practices (anticipation, transactional and relational interactions, and ad hoc collaborations) for resilience and performance.

Practice implications: These validated measures of organizational practices assess emergency response during crisis, with an emphasis on the actions and decisions of leadership as well as the management of organizational structures and processes. Organizations using these measures may subsequently modify preparedness and planning approaches to better manage future crises.

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: Enthusiasm has grown about using patients' narratives-stories about care experiences in patients' own words-to advance organizations' learning about the care that they deliver and how to improve it, but studies confirming association have not been published.

Purpose: We assessed whether primary care clinics that frequently share patients' narratives with their staff have higher patient experience survey scores.

Approach: We conducted a 1-year study of 5,545 adult patients and 276 staff affiliated with nine clinics in one health system. We used multilevel models to analyze survey data from patients about their experiences and from staff about exposure to useful narratives. We examined staff confidence in own knowledge as a moderator because confidence can influence use of new information sources.

Results: Frequency of sharing useful narratives with staff was associated with patient experience scores for all measures, conditional on staff confidence in own knowledge ( p < .01). For operational measures (e.g., care coordination), increased sharing correlated with subsequently higher performance for more confident staff and lower performance or no difference for less confident staff, depending on measure. For relational measures (e.g., patient-provider communication), increased sharing correlated with higher scores for less confident staff and lower scores for more confident staff.

Conclusion: Sharing narratives with staff frequently is associated with better patient experience survey scores, conditional on confidence in knowledge.

Practice implications: Frequently sharing useful patient narratives should be encouraged as an organizational improvement strategy. However, organizations need to address how narrative feedback interacts with their staff's confidence to realize higher experience scores across domains.