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Over the past 10 years, the field of health services and management research has seen renewed interest in the use of qualitative research methods. This article examines the volume and characteristics of qualitative research articles published in nine major health services and management journals between 1998 and 2008. Qualitative research articles comprise 9% of research articles published in these journals. Although the publication rate of qualitative research articles has not kept pace with that of quantitative research articles, citation analysis suggests that qualitative research articles contribute comparably to the field's knowledge base. A wide range of policy and management topics has been examined using qualitative methods. Case study designs, interviews, and documentary sources were the most frequently used methods. Half of qualitative research articles provided little or no detail about key aspects the study's methods. Implications are discussed and recommendations are offered for promoting the publication of qualitative research. [ABSTRACT FROM AUTHOR]

A study was undertaken to examine how different hospital clinical settings compare in their capacity for physicians to attend to safety and employ a learning approach to error. Multiple qualitative methods were used to examine medical residency teams in the emergency department, surgery department, and the medical intensive care unit. The focus was on how physicians responded to errors that occurred and safety-related issues, and what features of the surrounding work context were associated with those responses. Observations of 3 separate medical residency team's everyday work were conducted over three 3-week spans, and follow-up interviews with select team members were conducted after each observational period. Evidence supported that physician capacity for attending to safety and error is shaped by structural features of the surrounding work context within hospitals, as well as the cultural dynamics inherent in physician groups working in a given clinical setting. Compared with the emergency department and surgery, the medical intensive care unit offered the greatest potential from a work setting perspective to have heightened physician attention to safety and error. This was due to its more collegial environment, the low permeability of its doctors and patients, more available physician downtime and group interactions, fewer disruptions, and greater work predictability. The emergency department had less capacity because of its intense workload, excessive disruptions, and high unpredictability of the clinical work found there. Surgery's capacity to deal with error and safety issues was adversely affected by the emphasis on hierarchy among surgeons, the high permeability of surgeons across hospital work settings, emphasis on individual blame when mistakes occurred, and workload. These findings highlight the necessity for health care organizations to conduct regular assessments of their clinical environments to help identify the workplace factors that shape clinician approach to safety and error. It also calls into question the singular, uniform approaches to enhancing quality and safety within health care organizations. [ABSTRACT FROM AUTHOR]

Purpose: Medical home care has been identified as a model for improving primary care delivery and population-specific quality and safety outcomes. Questions remain how this model affects older adult quality. This systematic review addresses 2 important questions: Are quality and safety outcomes associated with medical home and patient-centered interventions, and how is quality studied in older adult primary care research?, Methods: The authors searched MEDLINE for articles that examined interventions that were associated with medical home principles. Each article was evaluated using a standardized data abstraction form. Studies were categorized according to how interventions influenced specific quality and safety outcomes-improved clinical and treatment measures and care delivery processes-for older adults., Results: Thirteen research studies were identified by the authors. A great deal of variety exists in both research design and how quality and safety outcomes for older adults are operationalized in primary care. In general, studies indicate potentially beneficial relationships between 3 types of medical home interventions targeting health care utilization, disease management, and patient-provider communication to improved quality outcomes., Conclusion: It would be advantageous for practices looking to align with patient-centered medical home quality and safety goals to consider the needs of older adults when redesigning care delivery.

In 2008, the Centers for Medicare & Medicaid Services (CMS) implemented a policy of not paying hospitals for the care of several preventable hospital-acquired conditions. The CMS policy is a unique value-based purchasing initiative because it relies on penalties rather than on rewards. Because of its novelty, less is known in advance about how this type of payment approach might work, get implemented, or be viewed by stakeholders in health care. As a result, the early published literature focusing on the CMS policy may serve as an important frame of reference among managers, policy makers, and researchers for guiding attitudes and behaviors. This review examines over an initial 3-year period academic and trade articles addressing the CMS policy to gain the impressions, guidance, and content provided in this literature. Key findings include an inordinately small number of articles focused on the new CMS policy; little original research or empirical prediction on CMS policy implementation and outcomes; a highly opinionated, non-evidence-based literature; a literature less able to address the policy impact for specific preventable complications or hospital settings; and a high percentage of articles making inconsistent, broad-based linkages between the CMS policy and specific quality improvement initiatives that potentially limit the policy's long-term acceptance as an improvement strategy.

Background: The study of patient safety can benefit from greater methodological diversity to improve scientific knowledge and to increase the effectiveness and tailoring of strategies aimed at improving it., Methodological Diversity to Better Capture Causal Mechanisms and Processes: Additional methods for studying patient safety and errors to reflect the complexity of what goes on within health care organizations should be made routine. Interviews, focus groups, and observation--the predominant methods used in qualitative research--are infrequently used in health services research, generally and specifically in the study of errors and patient safety. However, they offer several advantages over quantitative designs. They often are less expensive and quicker to implement; they may not need a lot of advance work; and they can be used to study retrospectively a particular failure event, outcome, or situation., Action Steps: Organizations can use an action agenda to better implement and promote the use of qualitative methods. Implementing these action steps can help achieve the attributes-trust, honesty, communication, participation, and efficiency-necessary to facilitate the qualitative approach in health care work settings., Summary and Conclusion: Qualitative approaches should be used in studying patient safety as a complement to (not a substitute for) quantitative approaches. They can be implemented more easily in organizations through structural and cultural adjustments that provide a more supportive foundation for this work.

This study presents findings from a national survey of physicians working in the emerging career of hospital medicine. It finds that female hospitalists earn significantly less annually than male hospitalists, despite similar work schedules and commitments; that these similarities in work and differences in pay remain even for male and female hospitalists who are married and have children; and that female hospitalists maintain positive feelings toward their work careers despite assuming multiple work and nonwork roles simultaneously. The results present a unique picture of female physicians' career experiences in toto. They have implications for how health care organizations and managers should think about the contemporary female physician (e.g., her career development needs and workplace challenges);for female physicians' need to gain greater equity vis-à-vis men within the profession; and for the kinds of questions researchers should raise around physician gender in their work.

Six core competencies have been developed for use by residency programs in assessing individual resident training outcomes. The authors propose that it is important to consider the role of residency culture and work context in helping residents achieve the required competencies. Specifically, the development of a learning-oriented culture and favorable work conditions that facilitate the presence of that culture should be a high priority for residency programs and the organizations (e.g., hospitals) in which they are housed. This places formal accountability at the doorstep of these programs and organizations in helping to create a "competent" resident. Using ideas from management theory, the authors identify specific attitudes, behaviors, and interactions that define a learning culture and show their usefulness when applied to residents' achievement of the competencies. They assert that current features of everyday resident work life decrease the chances that such attitudes, behaviors, and interactions will occur. Identifying and prioritizing the components of desired work environments for promoting a learning-oriented culture, in addition to assessing the presence or absence of both the components and learning best practices within residency programs, should become normal activities that complement the process of assessing competencies.

The results of a multimethod, qualitative data collection approach reveal a high level of consistency between early-stage dynamics identified in service line implementation and dynamics viewed within life cycle theory as more observable during the birth stage of development. This finding supports the idea that service line implementation unfolds similarly compared with other types of structures. In addition, it presents a more complex view of service line implementation at any given point in time by linking its unique aspects with issues and dynamics particular to the developmental stage in which the structure exists. The organization examined was the Behavioral Health Service Line of the Upstate New York Veterans Healthcare Network.

The present study advances our understanding of both physician adaptation and the physician-organization relationship in a managed care environment defined by structural diversity and constant change. It does so through a longitudinal examination of a single group of physician-employees experiencing their work lives within a nonprofit health maintenance organization (HMO) in the midst of major strategic developments. Using interview, observation, and archival data collected over a five-year period, the analysis reveals that the form and substance of individual physician adaptation to organizational life is dependent upon social exchanges over time with the HMO, making it an emergent, evolutionary process rather than a pre-determined, static phenomenon. However, the results also demonstrate that physician adaptive response to rapid, unpredictable organizational change is slow and delayed, in particular when this change makes physicians more dependent on their employing organization. This confers an advantage onto the organization vis-à-vis professionals in interpreting and responding to environmental change. These insights should encourage sociologists to employ research designs and contingency models of physician attitudes and behavior that capture the dynamic and particularistic nature of everyday physician work life in contemporary health care.

Health care researchers and managers have viewed physicians traditionally through three major lenses, that is, as professionals, suppliers, and caregivers. This article makes a case for another lens, that of the physician as worker. The worker perspective complements these existing perspectives, serves as a generative metaphor in raising new assumptions and questions about physicians, and provides physicians with a dimensionality necessary because of increasing diversity within and external to the medical profession.

The growth of a medical management specialty is a significant event associated with managed care. Physician executives are lauded for their potential in bridging the clinical and managerial realms. They also serve as a countervailing force to help the medical profession and patients maintain a strong voice in healthcare decision making at the strategic level. However, little is known about their work loyalties. These attitudes are important to explore because they speak to whose interests physician executives consider and represent in their everyday management roles. If physician executives are to maximize their effectiveness in the healthcare workplace, both physicians and organizations must view them as credible sources of authority. This study examines organizational and professional commitment among a national sample of physician executives employed in managed care settings. Data used for the analysis come from a national survey conducted through the American College of Physician Executives in 1996. The findings support the notion that physician executives can and do express simultaneous loyalty to organizational and professional interests. This dual commitment is related to other work attitudes that contribute to success in the management role. In addition, it appears that situational factors increase the chances for dual commitment. These factors derive from a favorable work environment that includes both organizational and professional socialization in the management role. The results of the study are useful in specifying the training and socialization needs of physicians who wish to do management work. They also provide a rationale for collaboration between healthcare organizations and rank-and-file physicians aimed at cultivating physician executives who are credible leaders within the healthcare system.

This article explores the current trends and issues surrounding physician unionization in the United States, using data from secondary sources and nine interviews with leaders of organizations at the forefront of physician unionizing efforts. Several key points are supported by these data and prior unionization research. First, unions should become a viable organizing alternative for the almost 50% of doctors who are salaried employees because of fewer legal barriers to collective representation, the involvement of national labor unions with resources to spend on organizing, more physicians belonging to demographic groups less hostile to organized labor. and work-related pressures faced by physician-employee under managed care. A second key point is that unions will find it difficult to represent self-employed physicians because of the influence of organized medicine and legal barriers to gaining collective bargaining rights for this group. This discussion is intended to raise awareness of the physician union issue among health care policy-makers and researchers.

There is interest in promoting greater use of qualitative methods in health care research. However, little is known about the volume or characteristics of published studies that use qualitative methods. This article explores these issues through a systematic review of 3 years (1995-1997) of articles classified as research in nine core health services research and management journals. The findings show that only about one in seven published research articles used qualitative methods. Two of the nine journals reviewed contributed 45 percent of the total number of articles using qualitative methods. Four journals contributed a combined 2 percent of this total number. The primary purposes in using these methods are description and articulating stakeholder perspectives. There is no standard number of pages devoted by journals to these studies or evidence that they require more journal space on average than quantitative studies. Most of the studies reviewed presented little or no information on methodology. These findings clarify future areas of emphasis for both editors and researchers wishing to promote the use of qualitative methodology in published health care research.

This paper examines professional commitment among physician executives working in managed care settings in the United States. The rise of an 'administrative elite' in medicine is central to the notion that physicians preserve their professional dominance despite changes in their prestige, work and employment status. Implicit in the notion of Freidson's restructuring perspective, physician executives presumably remain dedicated to professional interests in their management roles. The findings of a national survey support this assumption. Physician executives maintain meaningful, stable levels of professional commitment over time in management and the organization. This commitment is positively related to work-related characteristics involving favorable perceptions of the management job and physical and mental 'connection' to the practice of medicine. Belief in one's ability to successfully deliver appropriate clinical care, however, moderates the positive association between involvement in the management job and professional commitment. The findings provide a rationale for the maintenance of professional loyalty among physicians in management rooted in the work-related perceptions and activities of the individual physician executive.

This study looks at the legitimation of medical management and its effect on the likelihood of physician executives practicing medicine. The findings of a national survey show that several individual-level characteristics associated with legitimation such as working in senior management positions and for-profit organizations lower the probability that a physician executive will also be an active clinician. In addition, physician executives possessing graduate management degrees are more likely not to practice medicine than individuals without a degree. These results suggest that the specialty of medical management should pay greater attention to its unique qualities as it legitimizes if it is to be of long-term value to health care organizations and rank-and-file physicians.

This paper examines characteristics, job involvement, and career stage differences among 294 physician executives working in managed care settings. The following research questions guide the study: What types of physicians are currently in managerial roles in these settings? What role (if any) does medical career stage play in physician executives' professional and job-related attitudes? What factors are related to physician executives' involvement in their management roles? Several observations are made from the findings. First, contemporary physician executives see management as an exciting alternative career that involves multiple work loyalties, weaker beliefs in traditional professional values, and the sacrifice of significant amounts of clinical for management work. Second, these trends are more pronounced for physician executives at earlier points in their medical careers, although their work loyalties to profession and employing organization are weaker than older physician executives' loyalties. Younger individuals' involvement in management work, more than older individuals' involvement, appears to depend upon the surrounding work climate within the organization. Finally, the amount of time spent by physician executives as clinicians is inversely related to how psychologically attached they are to management, regardless of career stage.