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Background The health care system in the United States is costly with high variance in quality. There is growing interest in transformational performance improvement initiatives, such as the Lean management system, to eliminate waste and inefficiency and improve quality of care for patients. Methods A national survey of all 4,500 short-term acute general medical/surgical and pediatric hospitals in the United States was fielded between May and September 2017 by the Survey Data Center of the American Hospital Association. Results Responses were received from 1,222 hospitals (27.3% response rate). Sixty-nine percent (69.3%) reported use Lean or related Lean plus Six Sigma or Robust Process Improvement approaches. Not-for-profit hospitals, hospitals located in metro/urban areas, those belonging to a system/network, and those with 100–399 beds were most likely to be engaged in these activities and for an average of 5.2 years. However, only 12.6% (n = 102) of hospitals reported being at a mature hospitalwide stage of implementation. The degree of maturity, leadership commitment, daily management system use, and training were each positively associated with reported positive performance outcomes. Conclusion A majority of hospitals have adopted Lean-based transformational performance improvement approaches but with wide variance in the degree of implementation. It takes time for Lean to gain traction. The length of time doing Lean is positively associated with implementation progress and reported positive performance impacts. The extent to which Lean has an organizationwide performance impact awaits further research that links the variables in this study with objective cost and quality measures.

Background Multi-stakeholder alliances – groups of payers, purchasers, providers, and consumers that work together to address local health goals – are frequently used to improve health care quality within communities. Under the Aligning Forces for Quality (AF4Q) initiative, multi-stakeholder alliances were given funding and technical assistance to encourage the use of health information technology (HIT) to improve quality. We investigated whether HIT adoption was greater in AF4Q communities than in other communities. Methods Drawing upon survey data from 782 small and medium-sized physician practices collected as part of the National Study of Physician Organizations during July 2007 – March 2009 and January 2012—November 2013, we used weighted fixed effects models to detect relative changes in four measures representing three domains: use of electronic health records (EHRs), receipt of electronic information from hospitals, and patients’ online access to their medical records. Results Improvement on a composite EHR adoption measure was 7.6 percentage points greater in AF4Q communities than in non-AF4Q communities, and the increase in the probability of adopting all five EHR capabilities was 23.9 percentage points greater in AF4Q communities. There was no significant difference in improvement in receipt of electronic information from hospitals or patients’ online access to medical records between AF4Q and non-AF4Q communities. Conclusion By linking HIT to quality improvement efforts, AF4Q alliances may have facilitated greater adoption of EHRs in small and medium-sized physician practices, but not receipt of electronic information from hospitals or patients’ online access to medical records. Implications Multi-stakeholder alliances charged with promoting HIT to advance quality improvement may accelerate adoption of EHRs.

The healthcare industry must change in order to provide higher quality care and lower costs for patients; one method to improve both cost and quality used in Wisconsin and California is leveraging publicly reported claims and costs data. Wisconsin has been building comprehensive, publicly available clinical and administrative data sets: the Wisconsin Collaborative for Healthcare Quality (WCHQ) established in 2003 and the Wisconsin Health Information Organization (WHIO) established in 2009. The WCHQ and the WHIO allow physician groups to compare themselves with one another on cost and quality across 920 distinct episode treatment groups (ETGs). The ETGs include all components of care for a specific disease during a defined period. Since 2002 California has developed public reporting of quality data for physician groups and health plans through its Integrated Healthcare Association (IHA) and since 2008 its Right Care Initiative (RCI). In both states these data are used to identify best practices and opportunities for improvement, enhance care outcomes, and increase value for patients.

Background In 2008, hospitals were selected to participate in the California Healthcare-Associated Infection Prevention Initiative (CHAIPI). This research evaluates the impact of CHAIPI on hospital adoption and implementation of evidence-based patient safety practices and reduction of health care–associated infection (HAI) rates. Methods Statewide computer-assisted telephone surveys of California's general acute care hospitals were conducted in 2008 and 2010 (response rates, 80% and 76%, respectively). Difference-in-difference analyses were used to compare changes in process and HAI rate outcomes in CHAIPI hospitals (n = 34) and non-CHAIPI hospitals (n = 149) that responded to both waves of the survey. Results Compared with non-CHAIPI hospitals, CHAIPI hospitals demonstrated greater improvements between 2008 and 2010 in adoption (P = .021) and implementation (P = .012) of written evidence-based practices for overall patient safety and prevention of HAIs and in assessing their compliance (P = .033) with these practices. However, there were no significant differences in the changes in HAI rates between CHAIPI and non-CHAIPI hospitals over this time period. Conclusions Participation in the CHAIPI collaborative was associated with significant improvements in evidence-based patient safety practices in hospitals. However, determining how evidence-based practices translate into changes in HAI rates may take more time. Our results suggest that all hospitals be offered the opportunity to participate in an active learning collaborative to improve patient safety.

Context This systematic review provides a synthesis of the growing field of public health systems research related to the structure and organization of state and local governmental public health agencies. It includes an overview of research examining the influence of organizational characteristics on public health performance and health status and a summary of the strengths and gaps of the literature to date. Evidence acquisition Data were retrieved through an iterative process, beginning with key word searches in three publication databases (PubMed, JSTOR, Web of Science). Gray literature was searched through the use of Google Scholar™. Targeted searches on websites and key authors were also performed. Documents underwent an initial and secondary screening; they were retained if they contained information about local or state public health structure, organization, governance, and financing. Evidence synthesis 77 articles met the study criteria. Public health services are delivered by a mix of local, state, and tribal governmental and nongovernmental agencies and delivered through centralized (28%); decentralized (37%); or combined authority (35%). The majority of studies focused on organizational characteristics that are associated with public health performance based on the 10 Essential Public Health Services framework. Population size of jurisdiction served (>50,000); structure of authority (decentralized and mixed); per capita spending at the local level; some partnerships (academic, health services); and leadership of agency directors have been found to be related to public health performance. Fewer studies examined the relationship between organizational characteristics and health outcomes. Improvements in health outcomes are associated with an increase in local health department expenditures, FTEs per capita, and location of health department within local networks. Conclusions Public health systems in the U.S. face a number of critical challenges, including limited organizational capacity and financial resources. Evidence on the relationship of public health organization, performance, and health outcomes is limited. Public health systems are difficult to characterize and categorize consistently for cross-jurisdictional studies. Progress has been made toward creating standard terminology. Multi-site studies that include a mix of system types (e.g., centralized, decentralized) and local or state characteristics (e.g., urban, rural) are needed to refine existing categorizations that can be used in examining studies of public health agency performance.

Background This research analyzes the relationship between hospital use of automated surveillance technology (AST) for identification and control of hospital-acquired infections (HAI) and implementation of evidence-based infection control practices. Our hypothesis is that hospitals that use AST have made more progress implementing infection control practices than hospitals that rely on manual surveillance. Methods A survey of all acute general care hospitals in California was conducted from October 2008 through January 2009. A structured computer-assisted telephone interview was conducted with the quality director of each hospital. The final sample includes 241 general acute care hospitals (response rate, 83%). Results Approximately one third (32.4%) of California's hospitals use AST for monitoring HAI. Adoption of AST is statistically significant and positively associated with the depth of implementation of evidence-based practices for methicillin-resistant Staphylococcus aureus and ventilator-associated pneumonia and adoption of contact precautions and surgical care infection practices. Use of AST is also statistically significantly associated with the breadth of hospital implementation of evidence-based practices across all 5 targeted HAI. Conclusion Our findings suggest that hospitals using AST can achieve greater depth and breadth in implementing evidenced-based infection control practices.

Background There remains an ongoing need to reduce tobacco use in the U.S. Physician organizations, such as medical groups, can support healthcare providers to be more effective in their delivery of tobacco cessation by adopting practices recommended in the Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence (PHS Guideline). Purpose To document the extent to which activities to reduce tobacco use, as recommended in the PHS Guideline as system-level interventions, are provided within large medical groups in the U.S. Methods During 2006–2007, data were collected on 339 medical groups operating in the U.S., with 20 or more physicians treating at least one of four chronic conditions. Organizations were surveyed regarding activities to reduce tobacco use as recommended in the PHS Guideline as system-level interventions (i.e., tobacco-use status documentation, policies to promote provider interventions, and staff dedicated to treating tobacco dependence). Between 2008 and 2009, bivariate associations and multivariate logistic regression models assessed the relationship of organizational characteristics and external incentives with adoption of systems strategies for treating tobacco dependence. Results Nearly 83% of medical groups with 20 or more physicians operating in the U.S. in 2006–2007 have adopted one or more strategies recommended as effective to support the treatment of tobacco dependence. However, only 5.6% of medical groups engage in all eight tobacco control activities examined in this study. The two factors that were associated most consistently with medical group policies to treat tobacco dependence were the patient-centeredness of the organization and participation in a quality demonstration program. Conclusions There is much room for improvement in increasing medical group adoption of systems strategies to reduce tobacco use. The findings in this paper suggest recommendations to achieve these improvements.

There is evidence that health information technology can improve quality, safety and reduce costs but that health care providers needed more information about how to implement these technologies to realise its potential. This paper summarises the research and proposes a theory of implementation based on the research evidence. The second part describes two implementations of electronic medical record systems and compares the theory against the findings of these two case studies. The paper provides implementers with research-informed guidance about effective implementation, contributes to developing implementation theory and notes policy implications for current national strategies for IT in health.

Article-at-a-Glance Background It has been five years since the Institute of Medicine (IOM) report, Crossing the Quality Chasm , proposed systemwide changes to transform our health care system. What progress has been made? What lessons have been learned? How should we move forward? Methods Semistructured telephone interviews were conducted with 16 health care providers and researchers at organizations involved in system redesign. The findings were supplemented with a focused literature review and discussions from a national expert meeting. Results Many promising and innovative examples of redesign were identified. However, even delivery systems that are redesigning care in pursuit of the six IOM aims face daunting challenges, reflecting the need to align system changes across multiple levels and to integrate redesign efforts with ongoing system features. Four success factors were reported by providers as crucial in overcoming redesign barriers: (1) directly involving top and middle-level leaders, (2) strategically aligning and integrating improvement efforts with organizational priorities, (3) systematically establishing infrastructure, process, and performance appraisal systems for continuous improvement, and (4) actively developing champions, teams, and staff. A framework that integrates these success factors to facilitate a systems approach to redesigning health care organizations and delivery systems for improved performance is provided. Conclusions Successful system redesign requires coordinating and managing a complex set of changes across multiple levels rather than isolated projects.

Article-at-a-Glance Background Use of electronic medical records (EMRs) in health care organizations can reduce medical errors and improve quality of care through physicians' increased use of evidence-based patient care processes. However, only 20%–25% of physician organizations have adopted EMRs. A study was undertaken to determine the characteristics of primary care medical groups that distinguish EMR adopter from nonadopter organizations. Methods A quantitative nationwide survey was undertaken of all primary care medical groups in the United States with 20 or more physicians; data were collected on 738 medical groups (70% response rate). Results Fewer than one-third of the medical groups reported having either patients' medical records or progress notes in an EMR. Large organizations with relatively fewer practice locations were more likely to adopt an EMR. Discussion Large medical groups are more likely to have the financial and human resources necessary to overcome barriers to the adoption of an EMR. Knowing the influence of the other organizational characteristics on EMR adoption will help prepare organizational leaders for the complicated process of achieving consensus among physicians and others in medical groups on the expenditure of funds and other resources to acquire an EMR. Financial incentives for all medical groups will help drive EMR adoption, but financial and technical assistance aimed specifically at smaller groups is particularly warranted. Widespread adoption of EMR among medical groups will take time.

As national health systems pursue the common goals of containing expenditure growth and improving quality, many have sought to replace autonomous modes (systems) of physician control that rely on initial professional training and subsequent peer review. A common approach has involved extending bureaucratic modes of physician control that employ techniques such as hierarchical coordination and salaried positions. This paper applies concepts from studies of professional work to frame an empirical analysis of emergent bureaucratic modes of physician control in US hospital-based systems. Conceptually, we draw from recent studies to update Scott's (Health Services Res. 17(3) (1982) 213) typology to specify three bureaucratic modes of physician control: heteronomous, conjoint, and custodial. Empirically, we use case study evidence from eight US hospital-based systems to illustrate the heterogeneity of bureaucratic modes of physician control that span each of the ideal types. The findings indicate that some influential analysts perpetuate a caricature of bureaucratic organization which underplays its capacity to provide multiple modes of physician control that maintain professional autonomy over the content of work, and present opportunities for aligning practice with social goals.

Background Health promotion programs can be effective in improving the delivery of clinical preventive services and in improving population health; however, the availability of health promotion programs offered through physician organizations, such as medical groups and independent practice associations, are largely unknown. Methods This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California, Berkeley, to document the extent to which physician organizations offer health promotion programs. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%. Results Overall, 60% of physician organizations offer at least one health promotion program targeting one or more of eight areas: prenatal education (42%), smoking cessation (39%), nutrition (39%), weight loss (34%), health risk assessments (25%), stress management (25%), substance abuse (20%), and sexually transmitted disease prevention (16%). Factors positively associated with offering health promotion programs include the following: outside reporting of quality measures, public recognition for quality measures, clinical information technology systems, being a medical group, and ownership by a hospital or health plan. Conclusions Physician organizations in the United States have a long way to go in offering these important programs to their patients. However, our findings also suggest that health plans, purchasers, and policymakers can play a positive role in increasing the use of these programs. By offering recognition and incentives for quality improvement, and by funding the expansion of information technology, the healthcare community can encourage and enable physician organizations to increase the availability of health promotion programs nationally.

Pressure for hospitals to maintain quality while lowering cost or provide greater quality at a given level of cost is particularly critical in intensive care services for which it is increasingly difficult to match revenues with costs, given reimbursement limits. At the same time, twofold to threefold differences in intensive care unit risk-adjusted mortality have been reported. This article provides a model for thinking about continuous improvement of intensive care services, draws on the National ICU Study to identify fundamental organizational and managerial processes associated with better performance, and offers a validated assessment instrument to be used as a tool for continuous improvement.