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The COVID-19 pandemic stressed the health care sector's longstanding pain points, including the poor quality of frontline work and the staffing challenges that result from it. This has renewed interest in technology-centered approaches to achieving not only the "Triple Aim" of reducing costs while raising access and quality but also the "Quadruple Aim" of doing so without further squeezing wages and abrading job quality for frontline workers. How can we leverage technology toward the achievement of the Quadruple Aim? I view this as a "grand challenge" for health care managers and policymakers. Those looking for guidance will find that most analyses of the workforce impact of technological change consider broad classes of technology such as computers or robots outside of any particular industry context. Further, they typically predict changes in work or labor market outcomes will come about at some ill-defined point in the medium to long run. This decontextualization and detemporization proves markedly problematic in the health care sector: the nonmarket, institutional factors driving technology adoption and implementation loom especially large in frontline care delivery, and managers and policymakers understandably must consider a well-defined, near-term, i.e., 5-10-year, time horizon. This study is predicated on interviews with hospital and home health agency administrators, union representatives, health care information technology (IT) experts and consultants, and technology developers. I detail the near-term drivers and anticipated workforce impact of technological changes in frontline care delivery. With my emergent prescriptions for managers and policymakers, I hope to guide sectoral actors in using technology to address the "grand challenge" inherent to achieving the Quadruple Aim.

Employee turnover is a growing challenge for health-care providers delivering patient care today. US population demographics are shifting as the population ages, which leaves the field of health care poised to lose key leaders and employees to retirement at a time when patient care has grown more complex. This means health care will lose its core of key employees at a time when skilled leadership and specialized knowledge is most needed and directly impacts health care's ability to deliver quality care. Operational succession planning (OSP) may be one solution to manage this looming challenge in health care, as the process identifies and develops the next generation of leadership. Thus, this exploratory national study used a quantitative and cross-sectional design to examine the relationship between OSP and employee turnover. Demographic and 10-point Likert scale data were collected from n = 66 medical practices, using an online survey instrument. Data were analyzed using various descriptive and inferential statistical methods. Distribution (frequency and chi-square) analyses of the study sample, one-way analysis of variance (ANOVA), and regression analyses were performed across seven demographic characteristics of the medical practices: Specialty, Ownership Structure, Number of full-time equivalent (FTE) Physicians, Number of FTE Clinical Employees, Number of FTE Nonclinical Employees, Number of FTE Employees Left Position, and Region. Study results provided statistically significant evidence to support the relationship between OSP and employee turnover, highlighting that OSP was associated with lower employee turnover. The finding suggests that OSP can serve as an effective mechanism for increasing employee retention.

Increasingly, addressing healthcare's grand challenges requires complex system-level adaptations involving continuously evolving teams and leaders. Although leadership development strategies have been shown to improve individual leader effectiveness, much less is known about how organization-level leadership development affects organization-level outcomes. To begin building an evidence base as well as encouraging evidence-based practices, the US-based National Center for Healthcare Leadership developed a program capitalizing on leaders' demonstrated interest in organizational competitiveness: the biennial Best Organizations for Leadership Development (BOLD) program. In this chapter, we describe the philosophy behind this unique survey program and summarize research to date on relationships between survey dimensions and organizational outcomes such as patient experience and financial performance. We conclude with a description of promising areas for future study.

Leading health care institutions have recommended greater alignment among health care and social services organizations as a strategy to improve population health. Deepening our understanding of how interorganizational relationships among health care and social service organizations influence care for people with complex needs could improve the design of interventions aimed at aligning these organizations to achieve health goals. Accordingly, we used qualitative methods to (1) elucidate the functions performed by health care and social service organizations caring for older adults and (2) investigate corresponding relationship forms. In-depth interviews with 175 representatives of health care and social service organizations in 10 communities were analyzed. Three distinct interorganizational relationships functions emerged: First, interorganizational relationships gave organizations a deeper and more accurate understanding of how their work was interdependent with the work of other organizations in the community. This function was achieved through coalitions that loosely tied large numbers of organizations and allowed information to flow among them. Second, interorganizational relationships allowed organizations to take joint action toward a shared goal, a function achieved in the form of pairs or small groups of organizations working closely together. Third, interorganizational relationships fostered accountability, with one organization advocating for the needs of clients or patients with another organization. Our results suggest that initiatives to promote regional alignment among health care and social services organizations may benefit from flexible models that anticipate a narrowing of partners to achieve tangible outcomes. Initiatives also need to accommodate low-level conflict that routinely exists among organizations in these sectors.

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.

Improving performance often requires creative ideas in extreme work settings like health care. Frontline workers are promising sources of creative ideas. The authors assert that their job dissatisfaction is positively associated with creativity in health care settings because negative emotion spurs creativity when tied to engaging work and that characteristics such as shorter tenure, greater role centrality, and high boundary spanning can strengthen this relationship. The authors find supporting evidence in data on ideas generated over 18 months by health professionals in 12 clinics. Results suggest that health care organizations should not overlook dissatisfied workers as valuable sources of creative improvement ideas.

The COVID-19 pandemic burdens health-care workers (HCWs) worldwide. Amid high-stress conditions and unprecedented needs for crisis management, organizations face the grand challenge of supporting the mental health and well-being of their HCWs. The current literature on mental health and well-being primarily focuses on improving personal resilience among HCWs. However, this puts the responsibility for coping with COVID-19-related stress almost fully on the individual. This chapter discusses an important alternative framing of this issue - how health-care organizations (HCOs) can facilitate recovery from work processes (i.e., returning to a baseline level by engaging in nonwork activities after work) for their workers. Based on a narrative review of the occupational health psychology literature, we provide practical strategies for supporting the four key recovery experiences of detachment, control, mastery, and relaxation, as well as present general recommendations about how to promote recovery. These strategies can help HCOs facing the grand challenge of sustaining worker well-being and functioning during the COVID-19 pandemic, as well as during future pandemics and for workers facing high work pressure in general.

BACKGROUND: Slow progress in quality improvement (QI) has prompted calls to identify new QI ideas. Leaders guiding these efforts are advised to use evidence-based tactics, or specific approaches to address a goal, to promote clinician and staff engagement in the generation and implementation of QI ideas, but little evidence about effective tactics exists. OBJECTIVE: Examine the association between leader tactics and the creativity, implementation outcome, and evolution of QI ideas from clinicians and staff. DESIGN: Prospective panel analysis of 220 ideas generated by 12 leaders and teams (N = 72 members) from federally qualified community health practices in one center over 18 months. Measures were extracted from meeting minutes (note-taking by a member during meetings) and expert panel review. Multi-level models were used. MEASURES: Leader tactics, idea creativity, implementation outcome, evolution pathways, center, and idea-submitter characteristics. RESULTS: Leaders used one of four approaches: no tactic, meeting ground rules, team brainstorming, or reflection on team process. Implemented ideas evolved in three pathways: Plug and Play, Slow Burn, and Iterate and Generate. Compared with no leader tactic, meeting ground rules resulted in ideas not significantly different in creativity, implementation outcome, or evolution pathway. Brainstorming was associated with greater idea creativity, idea implementation, and ideas following a Plug and Play path (low member engagement and implementation over 2 months or less). Reflection on team process was associated with idea implementation (versus not), and ideas following an Iterate and Generate path (high member engagement and implementation over 3 months or more). CONCLUSIONS: Two tactics, brainstorming and reflection, are helpful depending on goals. Brainstorming may aide leaders seeking disruptive change via more creative, rapidly implemented ideas. Reflection on team process may aide leaders seeking high-engagement ideas that may be implemented slowly. Both tactics may help leaders cultivate dynamics that increase implementation of ideas that improve healthcare.

Health care organizations often fail in their effort to implement care-improving innovations. This article differentiates role-changing innovations, altering what workers do, from time-changing innovations, altering when tasks are performed or for how long. We examine our hypothesis that the degree to which access to groups that can alter organizational learning—staff, management, and external network—facilitates implementation depends on innovation type. Our longitudinal study using ordinal logistic regression and survey data on 517 hospitals’ implementation of evidence-based practices for treating heart attack confirmed our thesis for factors granting access to each group: improvement team’s representativeness (of affected staff), senior management engagement, and network membership. Although team representativeness and network membership were positively associated with implementing role-changing practices, senior management engagement was not. In contrast, senior management engagement was positively associated with implementing time-changing practices, whereas team representativeness was not, and network membership was not unless there was limited management engagement. These findings advance implementation science by explaining mixed results across past studies: Nature of change for workers alters potential facilitators’ effects on implementation.

Background Central line-associated bloodstream infections (CLABSIs) are a common and costly quality problem, and their prevention is a national priority. A decade ago, researchers identified an evidence-based bundle of practices that reduce CLABSIs. Compliance with this bundle remains low in many hospitals. Purpose The aim of this study was to assess whether differences in core aspects of work environments-workload, quality of relationships, and prioritization of quality-are associated with variation in maximal CLABSI bundle compliance, that is, compliance 95%-100% of the time in intensive care units (ICUs). Methodology/approach A cross-sectional study of hospital medical-surgical ICUs in the United States was done. Data on work environment and bundle compliance were obtained from the Prevention of Nosocomial Infections and Cost-Effectiveness Refined Survey completed in 2011 by infection prevention directors, and data on ICU and hospital characteristics were obtained from the National Healthcare Safety Network. Factor and multilevel regression analyses were conducted. Findings Reasonable workload and prioritization of quality were positively associated with maximal CLABSI bundle compliance. High-quality relationships, although a significant predictor when evaluated apart from workload and prioritization of quality, had no significant effect after accounting for these two factors. Practice implications Aspects of the staff work environment are associated with maximal CLABSI bundle compliance in ICUs. Our results suggest that hospitals can foster improvement in ensuring maximal CLABSI bundle compliance-a crucial precursor to reducing CLABSI infection rates-by establishing reasonable workloads and prioritizing quality.

Dynamic service settings—characterized by workers who interact with customers to deliver services in a rapidly changing, uncertain, and complex environment (e.g., hospitals)—play an important role in the economy. Organizational learning studies in these settings have largely investigated autonomous learning via cumulative experience as a strategy for performance improvement. Whether induced learning through the use of deliberate learning activities provides additional performance benefits has been neglected. We argue that the use of deliberate learning activities offers performance benefits beyond those of cumulative experience because these activities counter the learning challenges presented by rapid knowledge growth, uncertainty, and complexity in dynamic settings. We test whether there are additional performance benefits to using deliberate learning activities and whether the effectiveness of these activities depends on interdisciplinary collaboration in the workgroup. We test our hypotheses in a study of 23 hospital neonatal intensive care units (NICUs) involved in a quality improvement collaborative. We find that using deliberate learning activities is associated with better workgroup performance, as measured by NICUs' risk-adjusted mortality rates for 2159 infant patients, but only after two years. In the shorter term, using these activities is associated with worse performance. By the third year, the positive impact of using deliberate learning activities is similar to the benefit of cumulative experience (18% and 20% reduction in odds of mortality, respectively). Contrary to prediction, interdisciplinary collaboration mediates, rather than moderates, the relationship between using deliberate learning activities and workgroup performance. Thus, our data suggest that using deliberate learning activities fosters interdisciplinary collaboration.

Amid persistent evidence that many patients do not receive guideline-based care, national quality campaigns have developed to motivate widespread adoption of evidence-based practices to improve quality of care. Recent examples include the 100,000 Lives and 5 Million Lives Campaigns sponsored by the Institute for Healthcare Improvement (Gosfield and Reinertsen 2005; Berwick et al. 2006; McCannon, Hackbarth, and Griffin 2007; American Heart Association; 2009), and the Door-to-Balloon (D2B) Alliance for Quality led by the American College of Cardiology (Krumholz et al. 2008). Although there is some debate regarding the magnitude of impact (Wachter and Pronovost 2006), evidence (Berwick et al. 2006; McCannon et al. 2006; Bradley et al. 2009a;) suggests that these campaigns can have measurable impact in increased adherence to guidelines and potentially marked reductions in preventable deaths. Despite the widespread participation by hospitals in such national quality campaigns, we know little about users' perspectives about what makes such campaigns more effective or less effective. Previous research has reported views of network sponsors and researchers concerning characteristics of effective learning networks (Ovretveit 2002; Ovretveit et al. 2002; Wilson, Berwick, and Cleary 2003; Ayers et al. 2005; McCannon and Perla 2009;), but these reports have not examined participant views. Nevertheless, participant views are important for understanding the characteristics of campaigns that enhance their effectiveness, for identifying why campaigns might be effective, and for describing the conditions under which campaigns may be more effective or less effective. This deeper understanding of campaigns may shed light into the process of effective dissemination of evidence-based practices to promote quality of care. Accordingly, we sought to understand the influence of a national quality campaign, the D2B Alliance, from the participants' perspective. The D2B Alliance was a national quality campaign, sponsored by the American College of Cardiology and 38 other professional organizations and agencies, to disseminate evidence-based practices in reducing delays to between-hospital presentation and percutaneous coronary intervention (PCI), or balloon angioplasty, for patients with ST-segment elevation myocardial infarction (STEMI). The D2B Alliance was an open and free campaign that enrolled more than 1,000 U.S. hospitals in its first year (Krumholz et al. 2008). Hospitals enrolled by having a letter signed by the senior administrator committing to the goal of the D2B Alliance, which was for 75 percent of patients with STEMI treated with PCI to receive therapy within 90 minutes of hospital arrival, the D2B time target set by national guidelines. The D2B Alliance promoted the implementation of evidence-based strategies (Bradley et al. 2006; Bradley et al. 2009a) for reducing D2B time by disseminating a toolkit and a change package as well as providing open access to webinars, an online community, and a mentor network. We addressed the following questions pertinent to national quality campaigns with our research. What characteristics of the campaign are viewed by participants as most effective? What are the mechanisms by which the campaign influences outcomes? And what are the contextual factors that modify the effectiveness of the campaign? Such information can be used by researchers, policy makers, and practitioners to anticipate the circumstances under which campaigns might be effective dissemination strategies and to include design features based on evidence about what participants view as most effective.

With half of the U.S. health care workforce reporting job dissatisfaction, achieving coordinated, team-based care is daunting. Yet, health care may need precisely these individuals to address this ...

This paper contributes to research on organizational learning by investigating specific learning activities undertaken by improvement project teams in hospital intensive care units and proposing an integrative model to explain implementation success. Organizational learning is important in this context because medical knowledge changes constantly and hospital care units must learn new practices if they are to provide high-quality care. To develop a model of factors affecting improvement project teams driving essential organizational learning in health care, we draw from three streams of related research—best-practice transfer (BPT), team learning (TL), and process change (PC). To test the model’s hypotheses, we collected data from 23 neonatal intensive care units seeking to implement new or improved practices. We first analyzed the frequency of specific learning activities reported by improvement project participants and discovered two distinct factors: learn-what (activities that identify current best practices) and learn-how (activities that operationalize practices in a given setting). Next, ordinary least squares (OLS) regression analyses supported three of our four hypotheses. Specifically, a high level of supporting evidence for a unit’s portfolio of improvement projects was associated with implementation success. Learn-how was positively associated with implementation success, but learn-what was not. Psychological safety was associated with learn-how, which was found to mediate between psychological safety and implementation success.

Increasingly, there is recognition of the need for individuals with expertise in both management and public health to help health care organizations deliver high-quality and cost-effective care. The Yale School of Public Health and Yale School of Management began offering an accelerated Master of Business Administration (MBA) and Master of Public Health (MPH) joint degree program in the summer of 2014. This new program enables students to earn MBA and MPH degrees simultaneously from 2 fully accredited schools in 22 months. Students will graduate with the knowledge and skills needed to become innovative leaders of health care organizations. We discuss the rationale for the program, the developmental process, the curriculum, benefits of the program, and potential challenges.

This chapter introduces the construct of “leader inclusiveness” – words and deeds exhibited by leaders that invite and appreciate others’ contributions. We propose that leader inclusiveness helps cross-disciplinary teams overcome the inhibiting effects of status differences, allowing members to collaborate in process improvement. The existence of a professional hierarchy in medicine and the differential status accorded to those in different disciplines are well established in the health care literature, as is the need for quality improvement. We build on this foundation to suggest that profession-derived status is positively associated with psychological safety (H1) – a key antecedent of speaking up and learning behaviour – in health care teams. We hypothesise that this effect varies across teams (H2), and furthermore, that leader inclusiveness predicts psychological safety (H3) and moderates the relationship between status and psychological safety (H4). Finally, we suggest psychological safety predicts “engagement in quality improvement work” (H5) and mediates the relationship between leader inclusiveness and engagement (H6). Survey data collected in 23 neonatal intensive care units involved in quality improvement projects support our hypotheses. These results provide insight into antecedents of and strategies for fostering improvement efforts in health care and other sectors in which cross-disciplinary teams engage in collaborative learning to improve products or services.

Substantial improvements are needed to achieve the U.S. healthcare system aim of providing patient-centered care. Healthcare staff (e.g., physicians and nurses) may be an important source of creati...

Background Research suggests that staff voice-discretionary communication of ideas, suggestions, concerns, or opinions about work-related issues with the intent to improve organizational or unit functioning-is associated with quality improvement, which most agree is needed in health care. Nevertheless, health professionals often do not voice. Little research has explored their reluctance to speak up and, relatedly, the conditions under which they voice. Purpose We examine the drivers of voice for health professionals in hospitals. Specifically, we investigate the factors that influence their voice, why these factors are influential, and the purposes for which staff use their voice. Methodology We conducted a qualitative study using data from 99 in-depth interviews with diverse staff at 12 randomly sampled hospitals in the United States. Data were collected from December 2007 to December 2008, the first year of a 4-year study of improvement. By national standards, all of the hospitals had significant room for improvement in their care of patients experiencing heart attack, suggesting that there were potentially issues and suggestions for staff to voice. Findings Factors related to individuals (e.g., tenure), work (e.g., work configuration), organizational context (e.g., culture), data (e.g., benchmarking), and the external environment (e.g., attention) influenced health professionals' voice. These factors shaped their sense of safety, efficacy, opportunity, and/or legitimacy, all of which affected their belief about the risk and benefit of voice and willingness to voice. They voiced for three purposes: to learn for themselves, inform others, and protect patients. Practice implications These findings indicate that hospitals and their leaders must attend to multiple factors (e.g., work configuration, culture, etc.) if they wish to increase staff voice in service of quality improvement. The presence of many influential factors suggests that there are several levers that leaders can use to elicit voice, noting that voice can be used in multiple ways to facilitate improvement.

This article examines the effect on quality improvement of two common but distinct approaches to organizational learning: importing best practices (an externally oriented approach rooted in learning by imitating others’ best practices) and internal creative problem solving (an internally oriented approach rooted in learning by experimenting with self-generated solutions). We propose that independent and interaction effects of these approaches depend on where organizations are in their improvement journey − initial push or later phase. We examine this contingency in hospitals focused on improving treatment time for patients with heart attacks. Our results show that importing best practices helps hospitals achieve initial phase but not later phase improvement. Once hospitals enter the later phase of their efforts, however, significant improvement requires creative problem solving as well. Together, our results suggest that importing best practices delivers greater short-term improvement, but continued improvement depends on creative problem solving.

Teamwork in health care settings is widely recognized as an important factor in providing high-quality patient care. However, the behaviors that comprise effective teamwork, the organizational factors that support teamwork, and the relationship between teamwork and patient outcomes remain empirical questions in need of rigorous study.To identify and review survey instruments used to assess dimensions of teamwork so as to facilitate high-quality research on this topic.We conducted a systematic review of articles published before September 2012 to identify survey instruments used to measure teamwork and to assess their conceptual content, psychometric validity, and relationships to outcomes of interest. We searched the ISI Web of Knowledge database, and identified relevant articles using the search terms team, teamwork, or collaboration in combination with survey, scale, measure, or questionnaire.We found 39 surveys that measured teamwork. Surveys assessed different dimensions of teamwork. The most commonly assessed dimensions were communication, coordination, and respect. Of the 39 surveys, 10 met all of the criteria for psychometric validity, and 14 showed significant relationships to nonself-report outcomes.Evidence of psychometric validity is lacking for many teamwork survey instruments. However, several psychometrically valid instruments are available. Researchers aiming to advance research on teamwork in health care should consider using or adapting one of these instruments before creating a new one. Because instruments vary considerably in the behavioral processes and emergent states of teamwork that they capture, researchers must carefully evaluate the conceptual consistency between instrument, research question, and context.

BACKGROUND Organizational culture is an important driver of organizational performance. However, little is known about the cultures of medical groups, which play an important role in health care. PURPOSE We sought to characterize the cultures of medical groups and identify factors that influence these cultures. METHODOLOGY We conducted a qualitative study of the organizational cultures of 8 U.S. multispecialty medical groups, using data collected during site visits and in-depth interviews with clinical and administrative staff (N = 69). Groups were randomly selected from those that participated in the second National Study of Physician Organizations using stratified sampling along three dimensions (i.e., ownership type, use of care management practices, and outcome performance). We analyzed the data to assess the presence of seven culture types-group, hierarchical, rational, developmental, quality oriented, patient centered, and physician centered-using the constant comparative method. FINDINGS We found that a multiplicity and diversity of cultures exist within and across multispecialty medical groups, with a dominance of patient-centered, physician-centered, rational, or quality-oriented cultures and less emphasis on group, developmental, and hierarchical cultures. Culture types that may seem antithetical, for example, patient-centered and physician-centered cultures, often coexisted within the same group. Across culture types, we found that six factors influenced medical group culture: financial, people, leadership, structural, processes, and environmental. PRACTICE IMPLICATIONS As medical groups adapt to changes under health care reform, their success likely depends on their having cultures that facilitate collaboration with other organizations (e.g., hospitals) that possess different cultures and adaptation to changes in payment and regulation. Our study suggests that some groups may not have the developmental and group cultures needed to adapt. Our study identifies six categories of levers they can use to alter their culture as desired.

Background Quality improvement collaboratives are an increasingly common strategy for implementing evidence-based practices in health care. However, research shows that many participating organizations do not achieve the level of performance improvement desired. Purpose This study examined the use of interorganizational learning activities (inter-OLAs) as an explanation for mixed performance improvement among collaborative participants. We tested the hypotheses that inter-OLA use is positively associated with participants' performance improvement and that this relationship is moderated by the use of intraorganizational learning activities (intra-OLAs) and quality-focused human resource (Q-HR) practices. Methodology We conducted a survey of organizational teams participating in 4 Institute for Healthcare Improvement Breakthrough Series collaboratives. Survey responses from 52 teams, regarding the use of inter-OLAs, intra-OLAs and Q-HR practices, were linked to performance improvement data obtained from the Institute for Healthcare Improvement and demographic data obtained from secondary sources. Findings The more collaborative teams used inter-OLAs, the more their organizations' performance improved. Contrary to our hypothesis, the use of intra-OLAs did not moderate this relationship; teams' use of intra-OLAs added to, but did not multiply, the effect of inter-OLA use. In contrast, an organization's use of Q-HR practices multiplied the performance benefit of inter-OLA use. Practice implications Our findings suggest that organizations that participate in collaboratives are more likely to improve their performance if they use the inter-OLAs offered by the collaborative. Our results also suggest that complementing high use of inter-OLAs with intra-OLA use and Q-HR practices enhances performance improvement. For collaborative sponsors, our findings imply that including activities that facilitate interorganizational and intraorganizational learning are worthwhile.

Background Popular quality improvement tools such as Six Sigma and Lean Systems (SS/L) claim to provide health care managers the opportunity to improve health care quality on the basis of sound methodology and data. However, it is unclear whether these 2 quality improvement tools actually improve health care quality. Methods The authors conducted a comprehensive literature review to assess the empirical evidence relating SS/L to improved clinical outcomes, processes of care, and financial performance of health care organizations. Results The authors identified 177 articles on SS/L published in the last 10 years. However, only 34 of them reported any outcomes of the SS/L projects studied, and less than one-third of these articles included statistical analyses to test for significant changes in outcomes. Conclusions This review demonstrates that there are significant gaps in the SS/L health care quality improvement literature and very weak evidence that SS/L improve health care quality.

The use of national quality campaigns to foster evidence-based hospital practices is increasing. Because campaigns typically do not limit access to their resources, they may influence non-enrolled hospitals as well.To examine the relative impact of a national campaign, the Door-to-Balloon (D2B) Alliance, on enrolled and non-enrolled hospitals.In this prospective cohort study, we compared the use of D2B Alliance resources (eg, webinars, online community, mentor network), changes in the use of strategies recommended by the D2B Alliance, and perceived impact of the D2B Alliance between hospitals that enrolled in the D2B Alliance (n=264) and hospitals that declined enrolment (n=101).More than half (53.2%) of non-enrolled hospitals reported using at least some of the resources made available by the D2B Alliance to improve door-to-balloon times. This compared with 83.5% of enrolled hospitals reporting that they used D2B Alliance resources (p0.01). Both enrolled and non-enrolled hospitals significantly increased their use of recommended hospital strategies between 2005 and 2008, although the use of strategies remained incomplete (35.5-91.5% use). There was no significant difference between the use of these strategies between enrolled and non-enrolled hospitals at follow-up (por = 0.51), adjusted for baseline use. About half of all hospitals reported that door-to-balloon times would have been worse at their hospital without the existence of the D2B Alliance.This research suggests that national quality campaigns with open access to campaign resources may have substantial spillover effects on non-enrolled hospitals.

Background Despite decades of efforts to improve quality of health care, poor performance persists in many aspects of care. Less than 1% of the enormous national investment in medical research is focused on improving health care delivery. Furthermore, when effective innovations in clinical care are discovered, uptake of these innovations is often delayed and incomplete. In this paper, we build on the established principle of 'positive deviance' to propose an approach to identifying practices that improve health care quality. Methods We synthesize existing literature on positive deviance, describe major alternative approaches, propose benefits and limitations of a positive deviance approach for research directed toward improving quality of health care, and describe an application of this approach in improving hospital care for patients with acute myocardial infarction. Results The positive deviance approach, as adapted for use in health care, presumes that the knowledge about 'what works' is available in existing organizations that demonstrate consistently exceptional performance. Steps in this approach: identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e.g., proper medication use, timeliness of care); study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance; test hypotheses statistically in larger, representative samples of organizations; and work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practices. The approach is particularly appropriate in situations where organizations can be ranked reliably based on valid performance measures, where there is substantial natural variation in performance within an industry, when openness about practices to achieve exceptional performance exists, and where there is an engaged constituency to promote uptake of discovered practices. Conclusion The identification and examination of health care organizations that demonstrate positive deviance provides an opportunity to characterize and disseminate strategies for improving quality.

Quality improvement collaboratives are an increasingly common strategy for implementing evidence-based practices in health care. Most collaboratives are modeled after the Breakthrough Series (BTS) model, developed by the Institute for Healthcare Improvement (IHI). In the BTS collaborative model, IHI identifies a topic for which a large gap exists between actual and recommended care, assembles expert faculty to develop a “change package” of evidence-based practices to close the gap, and invites organizations to join the effort. Multidisciplinary teams from participating organizations then work together on the specified topic for approximately a year. Teams attend a series of multiday meetings, known as “Learning Sessions,” where they learn improvement techniques from experts and share their experiences implementing new practices with one another. Between Learning Sessions, teams implement changes in their own organizations using Plan-Do-Study-Act cycles in which they investigate quality problems, develop and implement small-scale changes, measure the effects, and make various changes for improvement. Teams learn from one another by participating in monthly conference calls, team-to-team telephone calls, listserv discussions, site visits to other organizations, monthly exchange of written reports detailing improvement activities, and monthly posting of performance data to the collaborative extranet. After the collaborative ends, teams summarize their results and lessons learned, and present them to nonparticipating organizations at conferences (Kilo 1998, 1999; IHI 2003). Previous studies of the impact of collaboratives on organizational performance have mixed results, with some demonstrating substantial impact on improvement (Horbar et al. 2001; Dellinger et al. 2005; Howard et al. 2007) and others finding no significant effect (Landon et al. 2004; Homer et al. 2005). The vast majority of these studies have examined collaboratives as a single intervention as opposed to the diverse set of features that comprise most collaborative models. A smaller group of studies has described the various features of collaboratives (e.g., Kilo 1998; Wilson, Berwick, and Cleary 2003; Ayers et al. 2005), but none has evaluated the influence of these various features on performance, particularly from the perspective of collaborative participants. Research by Fremont et al. (2006) and Leape et al. (2006) are notable exceptions. However, the former examined only three features of collaboratives, and the latter included a restricted sample of a single-state collaborative. Moreover, neither study empirically tested the relative helpfulness of various features of the collaboratives. Thus, we know little about which features are viewed as most helpful, why they are helpful, and which features are rated most highly by participants whose organizations are most successful in improving performance. This knowledge is central for researchers, practitioners, and policy makers seeking to use collaboratives effectively to improve quality of care. Therefore, we sought to examine Participants' views on the relative helpfulness of various features of collaboratives, why each feature was helpful, and which features the most successful participants viewed as most central to their success. We used quantitative and qualitative data from participants (53 teams) in four 2004–2005 BTS collaboratives. Findings from this study inform ongoing discussions about the most effective activities for promoting quality improvement. They also inform debates about whether the collaborative model can be modified to make it accessible to resource-constrained organizations without sacrificing the most valued features. For example, some have questioned whether multiday, face-to-face Learning Sessions, which require additional financial and nonfinancial investments are fundamental or can be replaced by 1-day or virtual sessions with equal success (Fremont et al. 2006). The findings from this study offer insight into which collaborative features should be maintained because of their value for participants.

Preventing central line-associated bloodstream infections (CLABSIs), a common and costly quality problem, is a national priority. Researchers have identified an evidence-based bundle of practices that reduce CLABSI yet hospital compliance with this bundle remains low. The purpose of this study is to assess whether differences in work environment -workload, quality of relationships, and prioritization of quality-are associated with variation in maximal CLABSI bundle compliance i.e., compliance 95-100% of the time in intensive-care units (ICUs). We conducted a cross-sectional study of U.S. hospital ICUs. Work environment and bundle compliance data were obtained from the 2011 Prevention of Nosocomial Infections & Cost Effectiveness Refined Survey completed by infection prevention directors, and ICU and hospital characteristics data from the National Healthcare Safety Network. Factor and multi-level regression analyses were conducted. Reasonable workload and prioritization of quality were found to be positive...

Failed innovation implementation is prevalent in health care organizations. Several of the challenges that implementation leaders face are known, but little is known about strategies they use to ov...

This paper examines the interaction of two qualitatively different approaches to learning: importing best practices (an externally-oriented approach rooted in learning by imitating others’ best practices) and internal problem solving (an internally-oriented approach rooted in learning by investigating one’s deficiencies). We propose competing hypotheses about their interactive effect, which we test in a study of hospital improvement in treatment time for patients with heart attack. We find a significant interaction in the shorter term (two years). Importing best practices was positively associated with improvement among hospitals that did not use internal problem solving, but had no effect among hospitals that used problem solving. Over a longer, four-year period, the interaction was non-significant; both approaches independently added to improvement. These results suggest that combining independently effective approaches does not multiply shorter-term improvement, but using both approaches helps to maxim...