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Supporting healthcare decision-making that is patient-centered and evidence-based requires investments in the development of tools and techniques for dissemination of patient-centered outcomes research findings via methods such as clinical decision support (CDS). This article explores the technical landscape for patient-centered CDS (PC CDS) and the gaps in making PC CDS more shareable, standards-based, and publicly available, with the goal of improving patient care and clinical outcomes. This landscape assessment used: (1) a technical expert panel; (2) a literature review; and (3) interviews with 18 CDS stakeholders. We identified 7 salient technical considerations that span 5 phases of PC CDS development. While progress has been made in the technical landscape, the field must advance standards for translating clinical guidelines into PC CDS, the standardization of CDS insertion points into the clinical workflow, and processes to capture, standardize, and integrate patient-generated health data.

Objective We conducted a horizon scan to (1) identify challenges in patient-centered clinical decision support (PC CDS) and (2) identify future directions for PC CDS. Materials and Methods We engaged a technical expert panel, conducted a scoping literature review, and interviewed key informants. We qualitatively analyzed literature and interview transcripts, mapping findings to the 4 phases for translating evidence into PC CDS interventions (Prioritizing, Authoring, Implementing, and Measuring) and to external factors. Results We identified 12 challenges for PC CDS development. Lack of patient input was identified as a critical challenge. The key informants noted that patient input is critical to prioritizing topics for PC CDS and to ensuring that CDS aligns with patients’ routine behaviors. Lack of patient-centered terminology standards was viewed as a challenge in authoring PC CDS. We found a dearth of CDS studies that measured clinical outcomes, creating significant gaps in our understanding of PC CDS’ impact. Across all phases of CDS development, there is a lack of patient and provider trust and limited attention to patients’ and providers’ concerns. Discussion These challenges suggest opportunities for advancing PC CDS. There are opportunities to develop industry-wide practices and standards to increase transparency, standardize terminologies, and incorporate patient input. There is also opportunity to engage patients throughout the PC CDS research process to ensure that outcome measures are relevant to their needs. Conclusion Addressing these challenges and embracing these opportunities will help realize the promise of PC CDS—placing patients at the center of the healthcare system.

Author(s): Harrison, Michael I; Shortell, Stephen M | Abstract: IntroductionOrganizations and systems that deliver health care may better adapt to rapid change in their environments by acting as learning organizations and learning health systems (LHSs). Despite widespread recognition that multilevel forces shape capacity for learning within care delivery organizations, there is no agreed-on, comprehensive, multilevel framework to inform LHS research and practice.MethodsWe develop such a framework, which can enhance both research on LHSs and practical steps toward their development. We draw on existing frameworks and research within organization and implementation science and synthesize contributions from three influential frameworks: the Consolidated Framework for Implementation Research, the social-ecological framework, and the organizational change framework. These frameworks come, respectively, from the fields of implementation science, public health, and organization science.ResultsOur proposed integrative framework includes both intraorganizational levels (individual, team, mid-management, organization) and the operating and general environments in which delivery organizations operate. We stress the importance of examining interactions among influential factors both within and across system levels and focus on the effects of leadership, incentives, and culture. Additionally, we indicate that organizational learning depends substantially on internal and cross-level alignment of these factors. We illustrate the contribution of our multilevel perspective by applying it to the analysis of three diverse implementation initiatives that aimed at specific care improvements and enduring system learning.ConclusionsThe framework and perspective developed here can help investigators and practitioners broadly scan and then investigate forces influencing improvement and learning and may point to otherwise unnoticed interactions among influential factors. The framework can also be used as a planning tool by managers and practitioners.

Background In response to growing pressures on primary care, leaders have introduced a wide range of workforce and practice innovations, including team redesigns that delegate some physician tasks to nonphysicians. One important question is how such innovations affect care team members, particularly in view of growing dissatisfaction and burnout among healthcare professionals. We examine the work experiences of primary care physicians and staff after implementing Lean-based workflow redesigns. This included co-locating physician and medical assistant dyads, delegating significant responsibilities to nonphysician staff, and mandating greater coordination and communication among all care team members. Methods The redesigns were implemented and scaled in three phases across 46 primary care departments in a large ambulatory care delivery system. We fielded 1164 baseline and 1333 follow-up surveys to physicians and other nonphysician staff (average 73% response rate) to assess workforce engagement (e.g., job satisfaction, motivation), perceptions of the work environment, and job-related burnout. We conducted multivariate regressions to detect changes in experiences after the redesign, adjusting for respondent characteristics and clustering of within-clinic responses. Results We found that both physicians and nonphysician staff reported higher levels of engagement and teamwork after implementing redesigns. However, they also experienced higher levels of burnout and perceptions of the workplace as stressful. Trends were the same for both occupational groups, but the increased reports of stress were greater among physicians. Additionally, members of all clinics, except for the pilot site that developed the new workflows, reported higher burnout, while perceptions of workplace stress increased in all clinics after the redesign. Conclusions Our findings partially align with expectations of work redesign as a route to improving physician and staff experiences in delivering care. Although teamwork and engagement increased, the redesigns in our study were not enough to moderate long-standing challenges facing primary care. Yet higher levels of empowerment and engagement, as observed in the pilot clinic, may be particularly effective in facilitating improvements while combating fatigue. To help practices cope with increasing burdens, interventions must directly benefit healthcare professionals without overtaxing an already overstretched workforce. Electronic supplementary material The online version of this article (10.1186/s12913-018-3062-5) contains supplementary material, which is available to authorized users.

Background: The Improving Diagnosis in Health Care report from the National Academies of Sciences, Engineering and Medicine (NASEM) provided an opportunity for many groups to reflect on the role they could play in taking actions to improve diagnostic safety. As part of its own process, AHRQ held a research summit in the fall of 2016, inviting members from a diverse collection of organizations, both inside and outside of Government, to share their suggestions regarding what is known about diagnosis and the challenges that need to be addressed. Content: The goals of the summit were to learn from the insights of participants; examine issues associated with definitions of diagnostic error and gaps in the evidence base; explore clinician and patient perspectives; gain a better understanding of data and measurement, health information technology, and organizational factors that impact the diagnostic process; and identify potential future directions for research. Summary and outlook: Plenary sessions focused on the state of the new diagnostic safety discipline followed by breakout sessions on the use of data and measurement, health information technology, and the role of organizational factors. The proceedings review captures many of the key challenges and areas deserving further research, revealing stimulating yet complex issues.

Background Although organizational context can affect the implementation of quality initiatives, we know less about the influence of contextual conditions on quality outcomes. We examined organizational features of primary care clinics that achieved greatest performance improvements after implementing Lean redesigns. Methods We used operational data and baseline (ie, pre-Lean implementation) surveys of 1333 physicians and staff in 43 primary care clinics located across a large ambulatory care system. Segmented regression with interrupted time series analysis was used to identify clinics with highest improvements in workflow efficiency, physician productivity, and patient satisfaction following Lean redesign. We conducted independent-samples t tests to identify contextual features of clinics that showed greatest improvements in performance outcomes. Results Clinics with highest increases in efficiency had most prior experience with quality improvement, compared with all other clinics. Efficiency gains were also found in clinics reporting highest levels of burnout and work stress prior to redesign. Highest improvements in physician productivity were associated with a history of change, staff participation, and leadership support for redesigns. Greatest improvements in patient satisfaction occurred in least stressful environments with highest levels of teamwork, staff engagement/efficacy, and leadership support. Conclusions Our findings encourage careful evaluation of clinic characteristics and capacity to effectively implement redesigns. Such evaluations may help leaders select interventions most appropriate for certain clinics, while identifying others that may need extra support with implementing change.

BACKGROUND Quality improvements are notoriously followed by "backsliding" or relapse to the status quo. This mixed-methods study examined the sustainment of Lean workflow redesigns for primary care teams several years after being implemented in a large, ambulatory care delivery system. METHODS We conducted qualitative interviews of 57 leaders and frontline providers, and fielded post-Lean implementation surveys to 1164 physicians and staff in 17 primary care clinics across the system. We analyzed interviews and conducted independent sample t tests to identify key factors that facilitated the sustainment of new workflows among primary care teams. All analyses were conducted after Lean redesigns were implemented and scaled across the system in 3 consecutive phases. RESULTS Adherence to Lean redesigns was highest in the pilot clinic, despite having the longest postdesign measurement period. Members of the pilot clinic reported greatest participation in designing workflows, were most highly engaged in quality improvement efforts, and held most favorable beliefs about Lean changes. Adherence to redesigns was lowest among clinic members in the second phase of implementation; these members also reported highest levels of burnout. CONCLUSIONS Staff participation in Lean redesign is a key to facilitating buy-in and adherence to changes. Change ownership and continued availability of time for improvement activities are also critical to the long-term success of Lean implementation in primary care.

As healthcare organizations look for ways to reduce costs and improve quality, many rely increasingly on allied healthcare professionals and, in particular, medical assistants (MAs) to supplement the work of physicians and other health professionals. MAs usually work in primary care, where they often play important roles on healthcare teams. Drawing on an empirical study of a large, multispecialty delivery system engaged in reconfiguration of primary care, we found that using MAs as flow managers required overcoming several challenges. These included entrenched social and occupational hierarchies between physicians and MAs, a lack of adequate training and mentorship, and difficulty attracting and retaining talented MAs. We offer several recommendations for healthcare organizations interested in using MAs as flow managers in their practices.

Background Public reporting of provider performance currently encompasses a range of measures of quality, cost, and patient experience of care. However, little is known about how medical groups use measures for performance improvement. This information could help medical groups undertake internal measurement while helping payers, policy makers, and measurement experts develop more useful publicly reported measures and quality improvement strategies. Methods An exploratory, qualitative study was conducted of ambulatory care medical groups across the United States that currently gather their own performance data. Results Eighty-three interviews were conducted with 91 individuals representing 37 medical groups. Findings were distilled into three major themes: (1) measures used internally, (2) strategies for using internal measurement for performance improvement, and (3) other uses of internal measurement. Medical groups used both clinical and business process measures, including measures from external measure sets and internally derived measures. Strategies for using internal measurement for quality improvement included taking a gradual, iterative approach and setting clear goals with high priority, finding workable approaches to data sharing, and fostering engagement by focusing on actionable measures. Measurement was also used to check accuracy of external performance reports, clarify and manage conflicting external measurement requirements, and prepare for anticipated external measurement requirements. Respondents in most groups did not report a need to assess costs of internal measurement or the capacity to do so. Conclusion Despite challenges and barriers, respondents found great value in conducting internal measurement. Their experiences may provide valuable lessons and knowledge for medical group leaders in earlier stages of establishing internal measurement programs.

We examined a wide range of performance outcomes after Lean methodology-a leading strategy to enhance efficiency and patient value-was implemented and scaled across all primary care clinics in a nonprofit, ambulatory care delivery system.Using a stepped wedge approach, we assessed changes associated with the phased introduction of Lean-based redesigns across 46 primary care departments in 17 different clinic locations. Longitudinal analysis of operational metrics included: workflow efficiency, physician productivity, operating expenses, clinical quality, and satisfaction among patients, physicians, and staff.We used interrupted time series analysis with generalized linear mixed models to estimate Lean impacts over time. Projected outcomes in the absence of changes (ie, counterfactuals) were compared with observed outcomes after Lean redesigns were implemented, and mean differences were assessed using 95% bias-corrected bootstrap confidence intervals (CIs).We observed systemwide improvements in workflow efficiencies (eg, 95% CI, 5.8-10.4) and physician productivity (95% CI, 3.9-27.2), with no adverse effects on clinical quality. Patient satisfaction increased with respect to access to care (95% CI, 15.2-20.7), handling of personal issues (95% CI, 2.1-6.9), and overall experience of care (95% CI, 11.0-17.0), but decreased with respect to interactions with care providers (95% CI, -13.4 to -5.7). Departmental operating costs decreased, and annual staff and physician satisfaction scores increased particularly among early adopters, with key improvements in employee engagement, connection to purpose, relationships with staff, and physician time spent working.Lean redesigns can benefit primary care patients, physicians, and staff without negatively impacting the quality of clinical care. Study results may lead other delivery system leaders to innovate using Lean techniques and may further enhance support for Lean learning among public and private payers.

Care management (CM) is a promising team-based, patient-centered approach “designed to assist patients and their support systems in managing medical conditions more effectively.” As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality–sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

Background Lean is a leading change strategy used in health care to achieve short-term efficiency and quality improvement while promising longer-term system transformation. Most research examines Lean intervention to address isolated problems, rather than to achieve broader systemic changes to care delivery. Moreover, no studies examine contextual influences on system-wide Lean implementation efforts in primary care. Purpose The aim of this study was to identify contextual factors most critical to implementing and scaling Lean redesigns across all primary care clinics in a large, ambulatory care delivery system. Methodology/approach Over 100 interviews and focus groups were conducted with frontline physicians, clinical staff, and operational leaders. Data analysis was guided by a modified Consolidated Framework for Implementation Research (CFIR), a popular implementation science framework. On the basis of expert recommendations, the modified framework targets factors influencing the implementation of process redesigns. This modified framework, the CFIR-PR, informed our identification of contextual factors that most impacted Lean acceptance among frontline physicians and staff. Findings Several domains identified by the CFIR-PR were critical to acceptance of Lean redesigns. Regarding the implementation process acceptance was influenced by time and intensity of exposure to changes, "top-down" versus "bottom-up" implementation styles, and degrees of employee engagement in developing new workflows. Important factors in the inner setting were the clinic's culture and style of leadership, along with availability of information about Lean's effectiveness. Last, implementation efforts were impacted by individual and team characteristics regarding changed work roles and related issues of professional identity, authority, and autonomy. Practice implications This study underscores the need for change leaders to consider the contextual factors that surround efforts to implement Lean in primary care. As Lean redesigns are scaled across a system, special attention is warranted with respect to the implementation approach, internal clinic setting, and implications for professional roles and identities of physicians and staff.

Background : Although management practices are recognized as important factors in improving health care quality and efficiency, most research thus far has focused on individual practices, ignoring or underspecifying the contexts within which these practices are operating. Research from other industries, which has increasingly focused on systems rather than individual practices, has yielded results that may benefit health services management. Purpose : Our goal was to develop a conceptual model on the basis of prior research from health care as well as other industries that could be used to inform important contextual considerations within health care. Methodology/approach : Using theoretical frameworks from A. Donabedian (1966), P. M. Wright, T. M. Gardner, and L. M. Moynihan (2003), and B. Schneider, D. B. Smith, and H. W. Goldstein (2000) and review methods adapted from R. Pawson (2006b), we reviewed relevant research from peer-reviewed and other industry-relevant sources to inform our model. The model we developed was then reviewed with a panel of practitioners, including experts in quality and human resource management, to assess the applicability of the model to health care settings. Findings : The resulting conceptual model identified four practice bundles, comprising 14 management practices as well as nine factors influencing adoption and perceived sustainability of these practices. The mechanisms by which these practices influence care outcomes are illustrated using the example of hospital-acquired infections. In addition, limitations of the current evidence base are discussed, and an agenda for future research in health care settings is outlined. Practice implications : Results may help practitioners better conceptualize management practices as part of a broader system of work practices. This may, in turn, help practitioners to prioritize management improvement efforts more systematically.

Background : A capable workforce is central to the delivery of high-quality care. Research from other industries suggests that the methodical use of evidence-based management practices (also known as high-performance work practices [HPWPs]), such as systematic personnel selection and incentive compensation, serves to attract and retain well-qualified health care staff and that HPWPs may represent an important and underutilized strategy for improving quality of care and patient safety. Purpose : The aims of this study were to improve our understanding about the use of HPWPs in health care organizations and to learn about their contribution to quality of care and patient safety improvements. Methodology/approach : Guided by a model of HPWPs developed through an extensive literature review and synthesis, we conducted a series of interviews with key informants from five U.S. health care organizations that had been identified based on their exemplary use of HPWPs. We sought to explore the applicability of our model and learn whether and how HPWPs were related to quality and safety. All interviews were recorded, transcribed, and subjected to qualitative analysis. Findings : In each of the five organizations, we found emphasis on all four HPWP subsystems in our conceptual model-engagement, staff acquisition/development, frontline empowerment, and leadership alignment/development. Although some HPWPs were common, there were also practices that were distinctive to a single organization. Our informants reported links between HPWPs and employee outcomes (e.g., turnover and higher satisfaction/engagement) and indicated that HPWPs made important contributions to system- and organization-level outcomes (e.g., improved recruitment, improved ability to address safety concerns, and lower turnover). Practice implications : These case studies suggest that the systematic use of HPWPs may improve performance in health care organizations and provide examples of how HPWPs can impact quality and safety in health care. Further research is needed to specify which HPWPs and systems are of greatest potential for health care management.

Introduction We address organizational learning about implementation context during setbacks to primary care redesign in an ambulatory system. The redesign expanded care teams and added a medical assistant assigned administrative and coordination tasks. The redesign was expected to improve care efficiency, prevention, and continuity. In response to setbacks, redesign and system leaders used understanding of context to plan system‐wide changes, as well as program adjustments. Doing so enhanced the redesign's prospects and contributed to system learning. Methods We conducted a 33‐month, mixed‐methods study. Qualitative data included quarterly calls with the redesign leaders and 63 activity log entries. There were three site visits; 73 interviews with practice leaders, providers, and medical assistants. Data analysis used categories from an implementation research framework; these were refined and then expanded inductively using log reports, debriefings with change leaders, and documents. Quantitative analysis used system operational data on chronic care, prevention, efficiency, productivity, and patient access. Results Redesigned teams were not implemented as widely or rapidly as anticipated and did not deliver hoped‐for gains in operational metrics. Interviews reported that team redesign was leading to improvements in chronic care and prevention and eased provider burden. Besides making small adjustments to cope with setbacks, redesign and system leaders engaged in more thorough organizational learning. They examined contextual challenges underlying setbacks and posing risks to the delivery system as a whole. Their responses to challenges helped strengthen the redesign's prospects, improved the delivery system's position in its labor market, and helped the system prepare to meet emerging requirements for value‐based care and population health. Conclusions This case points to benefits for both health care researchers and change practitioners of paying closer attention to how context affects implementation of organizational change, and to opportunities and conditions for learning from setbacks during change.

Our case studies provide preliminary evidence and examples of ways that high-performance work practices (HPWPs) can improve operations in healthcare organizations and can impact quality and safety....

OBJECTIVETo identify factors that may explain hospital-level differences in outcomes of programs to prevent central line–associated bloodstream infections.DESIGNExtensive qualitative case study comparing higher- and lower-performing hospitals on the basis of reduction in the rate of central line–associated bloodstream infections. In-depth interviews were transcribed verbatim and analyzed to determine whether emergent themes differentiated higher- from lower-performing hospitals.SETTINGEight US hospitals that had participated in the federally funded On the CUSP—Stop BSI initiative.PARTICIPANTSOne hundred ninety-four interviewees including administrative leaders, clinical leaders, professional staff, and frontline physicians and nurses.RESULTSA main theme that differentiated higher- from lower-performing hospitals was a distinctive framing of the goal of “getting to zero” infections. Although all sites reported this goal, at the higher-performing sites the goal was explicitly stated, widely embraced, and aggressively pursued; in contrast, at the lower-performing hospitals the goal was more of an aspiration and not embraced as part of the strategy to prevent infections. Five additional management practices were nearly exclusively present in the higher-performing hospitals: (1) top-level commitment, (2) physician-nurse alignment, (3) systematic education, (4) meaningful use of data, and (5) rewards and recognition. We present these strategies for prevention of healthcare-associated infection as a management “bundle” with corresponding suggestions for implementation.CONCLUSIONSSome of the variance associated with CLABSI prevention program outcomes may relate to specific management practices. Adding a management practice bundle may provide critical guidance to physicians, clinical managers, and hospital leaders as they work to prevent healthcare-associated infections.Infect Control Hosp Epidemiol 2015;00(0): 1–7

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.

The Institute of Medicine (IOM) report To Err Is Human introduced many patient safety advocates to the idea of developing hospitals into high-reliability organizations (HROs) (Kohn, Corrigan, and Donaldson 2000). The HRO model is appealing, in part, because it helps health care organizations incorporate lessons learned from high hazard industries, such as aviation and nuclear power. In contrast, normal accident theory (NAT), another research perspective that examines similar industries, did not receive such widespread attention from the health care sector. Although high reliability theory (HRT) and NAT were first cast as competing perspectives, they are now considered complementary (Perrow 1999a; Weick 2004). The two sets of HRT and NAT assumptions, concepts, and empirical predictions are best viewed as providing distinctive frames for understanding patient safety (Weick 2004).1 HRT and NAT are bodies of theory, research, and recommendations for practice and policy that evolved essentially in parallel. Hence, there are instances where these approaches diverge in their assumptions and in the organizational features they treat as critical, rather than offering competing hypotheses. Each frame poses significant questions and offers valuable insights into the pursuit of patient safety. Previous studies compared the two perspectives by applying them to disasters (e.g., Roberts 1990) or near disasters (e.g., Sagan 1993), but we apply them to five popular patient safety practices. We aim to identify distinctive contributions that HRT and NAT make to understanding the organizational conditions affecting patient safety in hospitals and the prospects for transforming hospitals into HROs. To accomplish this, like Snook (2000) we expand NAT beyond its original system-level focus to include processes and interactions among units and individuals. Moreover, we apply NAT to understanding incidents and component failure accidents in hospitals, not just to system accidents.

Practitioners renegotiated time use requirements in an electronic medical record (EMR), thereby improving fit between health information technology (HIT) and clinical practices. The study contains important implications for managing HIT implementation.

Background: Despite broad agreement among researchers about the value of examining how context shapes implementation of improvement programs and projects, limited attention has been paid to contextual effects on implementation of Lean. Purpose: To help reduce gaps in knowledge of effects of intraorganizational context, we researched Lean implementation initiatives in five organizations and examined 12 of their Lean rapid improvement projects. All projects aimed at improving clinical care delivery. Methodology/Approach: On the basis of the literature on Lean, innovation, and quality improvement, we developed a framework of factors likely to affect Lean implementation and outcomes. Drawing on the framework, we conducted semistructured interviews and applied qualitative codes to the transcribed interviews. Available documents, data, and observations supplemented the interviews. We constructed case studies of Lean implementation in each organization, compared implementation across organizations, and compared the 12 projects. Findings: Intraorganizational characteristics affecting organization-wide Lean initiatives and often also shaping project outcomes included CEO commitment to Lean and active support for it, prior organizational capacity for quality improvement-based performance improvement, alignment of the Lean initiative with the organizational mission, dedication of resources and experts to Lean, staff training before and during projects, establishment of measurable and relevant project targets, planning of project sequences that enhance staff capabilities and commitment without overburdening them, and ensuring communication between project members and other affected staff. Dependence of projects on inputs of new information technology was a barrier to project success. Incremental implementation of Lean produced reported improvements in operational efficiency and occasionally in care quality. However, even under the relatively favorable circumstances prevailing in our study sites, incremental implementation did not readily change organizational culture. Practice Implications: This study should alert researchers, managers, and teachers of management to ways that contexts shape Lean implementation and may affect other types of process redesign and quality improvement.

Implementation of Health Information Technologies (HIT) in hospitals encounters difficulties and leads to unintended consequences when there is poor fit between the practices, standards, and assump...

As of January 1, 1995, Israel's National Health Insurance (NHI) Law laid the foundations for regulating competition among the country's four private, not-for-profit sick funds. Prior to NHI the sick funds (SFs) had competed without governmental control. Extensive research on NHI implementation and the behavior of the sick funds (SFs) after passage of NHI reveals a paradoxical development: The NHI bill drew on the rhetoric of managed competition and did indeed establish a legal and structural framework for regulating competition among the SFs. Nevertheless, in practice, SF autonomy was constrained and competition over provision of statutory care was limited. Rather than fostering competition, the main thrust of the NHI reforms was to enhance central government's control over SF expenses in order to constrain government expenditures. The NHI reforms did encourage the SFs to cut costs and make visible service improvements. However, the reforms did not lead the SFs to reorganize, expand the scope of their services, or improve clinical quality, as the reformers had hoped. Nor did the reforms help eliminate the SF's operating deficits or insure financial stability for the whole health system. Furthermore, the reforms had unanticipated and undesired outcomes, including aggressive and illegal marketing by SFs and collaboration among SFs to restrict the extent of care provided under compulsory insurance. The Israeli case suggests that the theory of managed competition contains unrealistic assumptions about the types of competitive behavior that result from exposure to managed competition and the capacity of government and health providers to monitor quality. In addition to stemming from universal limitations to the managed competition model, the implementation pattern in Israel reflects local, historical forces and the interplay of Israel's powerful health system actors.

Turbulence, change, fragmentation, and multiple disruptive innovations characterize the current dynamic state of health services and delivery systems in the United States. Recent efforts to redesign and transform care delivery are searching for ways to overcome the challenges of fragmentation, inequality, and inappropriate care use while advancing the triple aims of better health and better care at lower cost for everyone. Health services research can contribute to these efforts by providing valid characterizations of the complex interactions among components of the current care delivery systems and by assessing impacts of efforts to redesign and improve care delivery. Mixed methods research can help investigators fully capture the complex interactions among system components, including interactions among multiple levels of analysis and over time. Through mixed methods, researchers can identify social, organizational, technical, and market contexts that shape the course and outcomes of improvement initiatives. Use of mixed methods may also make it easier for researchers to engage in dialogues with decision makers who formulate and implement programs of delivery system change, and to better communicate with other participants in the delivery system, including its users. This special issue of Health Services Research, sponsored by the Agency for Healthcare Research and Quality, illustrates how mixed methods studies can make important contributions to health services research.1 Furthermore, it seeks to move the field of mixed methods research toward creating a methodological mosaic that better corresponds to the complex phenomena. In this introduction, we describe the papers and briefly indicate where they fit into the emerging mixed methods mosaic. Then we provide some suggestions about what may be missing and anticipate a future state of a more integrated approach to health services research and richer dialogue between researchers and those engaged in health care. The growing role of mixed methods in health services research is evident from the publication of hundreds of mixed methods studies and recent overviews of best practices in mixed methods research (Palinkas, Aarons et al. 2011; Creswell et al. 2011; Curry et al. 2013; Ozawa and Pongpirul 2013; Zhang and Watanabe-Galloway 2013). This growing success reflects the capacity of mixed methods studies to capture the experiences, emotions, and motivations of people providing and receiving health care, as well as the objective conditions of care delivery. This wider use of mixed methods also reflects the ability of mixed methods to meet practical needs for assessing and understanding the complexity of health service delivery, which often results in an underlying emphasis on pragmatism. By applying a pragmatic mix of methods that work best in real-world situations, researchers thus find ways to overcome the assumed incompatibilities among research paradigms (Sale, Lohfeld, and Brazil 2002) and between qualitative and quantitative methods (Howe 2003; Onwuegbuzie and Leech 2005). Nevertheless, the recent proliferation of mixed methods research has exposed four areas needing more attention. First, until recently, most mixed methods studies embodied a form of “separate and unequal” in the ways that methods are used, data collected, and results published. Thus, there has been limited discussion about how to actually integrate multiple methods. Second, there has been a lack of common terminology for describing mixed methods designs and the multiple ways of combining methods. Third, the literature provides limited guidance about how to build the collaborative, cross-disciplinary teams that are required to execute a complicated mixed methods project and effectively manage the accompanying methodological and epistemological challenges. Fourth, at times pragmatism is insufficient and some paradigm issues still require attention. The six manuscripts in this issue highlight many of the reasons that mixed methods research has become popular while also addressing these four challenges; thus, they should help move mixed methods research toward a more complete methodological mosaic.

Research on organizational rhetoric and on joint action within organizations can be enriched through investigation of ideological accounts - public rhetorical statements that explain and justify collective actions. This paper assumes that ideological accounts, like other forms of organization rhetoric, are worthy of study in their own right - rather than being trivial reflections of “important” structures and processes, as many social scientists assume. The accounts examined here were provided by the heads of the Israel Medical Association (IMA), a national professional association and representatives of the physicians’ union during two conflicts between the IMA, government agencies, and the nation's largest health care organization. The IMA's accounts contributed to the dynamic flow of talk and action during these conflicts - rather than merely reflecting group interests. The IMA cases suggest that accounts usually change incrementally, as leaders respond to the ebb and flow of organizational interaction...

Health care organization leaders and policy makers seeking ways to reform the delivery of health care have become increasingly interested in transformational change. To foster understanding of how organizational transformation occurs and to stimulate further research, we report findings from a systematic review of empirical research on transformational change in the health care and non–health care literature, with a focus on the antecedents, processes (or paths), and outcomes of transformational change. Fifty-six studies, of which 13 were in health care, met our selection criteria. With one exception, all were published since 1990, indicating the recent upsurge of interest in this area. Limited differences were found between health care and non–health care studies. Available research documents the multiplicity of factors affecting change and the complexity of their interactions, but less information is available about the processes of transformational change than about its antecedents and consequences. Research and practice implications are discussed.

Until recently, studies of the impact of bureaucratic employment on professionals drew heavily on structural models, such as the theories of proletarianization and of professional stratification. In contrast, this paper develops a processual approach to professional control. This approach views control as resulting from struggles by occupational groups for institutional recognition and from struggles and negotiations within and between occupations. The structural and processual approaches are applied to the explanation of union activity-an increasingly prominent form of collective action among employed professionals. Unionization and union militancy are examined among Israeli physicians, who have a long history of bureaucratic employment. Although they are helpful, neither the proletarianization nor the stratification theories adequately account for the overall pattern of medical unionization or for individual and subgroup involvement in a lengthy physicians' strike. The processual approach points to several forces that help explain unionization and variations in strike involvement. These forces include institutional and contextual conditions, power differences between professional-subgroups, interactions among multiple actors in and around the professions, and the professionals' subjective interpretations and feelings. Although the processual approach is a loose perspective, rather than a tight-knit theory, it offers a better guide than the structural theories to investigating both professional-bureaucratic relations and collective actions aimed at enhancing professional control.

Many unintended and undesired consequences of healthcare information technologies (HIT) are generated by interactions between newly introduced HIT and the existing healthcare organization’s sociotechnical system--its workflows, culture, social interactions, physical environment, and technologies. This chapter presents and illustrates a model of these interactions that we call interactive sociotechnical analysis (ISTA). ISTA places special emphasis on recursive processes (i.e., feedback loops that alter the uses of the newly introduced HIT) promote second-level changes in the social system, and sometimes lead to changes in the new HIT systems themselves. We discuss ISTA’s implications for improving HIT implementation practices and suggest how clinicians, IT specialists, and managers can better anticipate likely consequences of introducing HIT; more effectively diagnose unforeseeable consequences which emerge during implementation; and better respond to these emerging consequences.

Article-at-a-Glance Background Implementation of health information technology (HIT) has encountered many difficulties and produced mixed outcomes. Yet Trinity Health, a major integrated delivery system, successfully leveraged implementation of a systemwide electronic health record (EHR) to promote process redesign and continuous quality improvement. Implementing a Systemwide EHR After several years of planning, two waves of EHR implementation were launched, in 2001 and 2003. One system HIT team collaborated with each hospital team for 18 months before its 24-hour transition to the EHR. During EHR planning, the system HIT team used five principles of redesign of care processes: (1) identify and address safety problems, (2) promote evidence-based practices, (3) reduce practice variations and standardize terminologies and care processes, (4) improve communication and relationships among clinician roles, and (5) augment multiple uses of data in HIT–supported care processes. Patient-centered work flows were developed to design improved patient care processes for different types of patients, such as medical inpatients and emergency outpatients. These admission-to-discharge work flows addressed gaps in quality, safety, and efficiency and helped ensure that the EHR and decision supports reflected crucial interactions among clinicians and with the patient. By the end of 2008, 13 of Trinity Health's 17 major health care organizations ("ministries") made the transformation to using EHRs. Discussion EHR–supported care redesign requires development of substantial system capacities in clinical informatics, customization and standardization of vendor's products, collaboration and coordination between system and hospital implementation teams, quality training for clinicians and change agents, and significant clinician participation in local preparations.

This paper analyzes forms of political involvement among consultants engaged in planned organizational change. This analysis is intended to contribute to research and theorizing on organizational change and to help consultants and managers cope with the challenges posed by organizational politics. Four consulting styles are distinguished, those that vary in the sources of consultant power, the consultants’ degree of involvement in organizational politics, the processes on which consultants and their clients rely to implement organizational change, and the consultants’ definition of the main client. Factors accounting for variations in the use of the four consulting styles are noted, along with conditions that may influence the effectiveness of these styles. Implications for consulting practice also are discussed.

Background: This article examines the development of transformation initiatives—deliberate attempts to achieve systemic changes and rapid performance improvements. Accounts of transformation initiatives often reveal little about past organizational and contextual conditions that contributed to success. Instead, these accounts concentrate on change barriers. Purpose: We seek to restore balance to this field by examining how antecedent system capacities contributed to a successful transformation initiative. Methodology: This article presents a case study of the first 2 years of a system redesign initiative at an integrated safety-net health system and provides a historical analysis of developments during the decade preceding the redesign. Findings: Beginning in the mid-1990s, Denver Health benefited from strong municipal support for its development and expansion. Gradually, it developed its financial and human resources, organizational structure, change strategy, change-management capabilities, information technology, and physical plant. These antecedent capacities all contributed to the implementation of the 2004 system redesign and helped Denver Health overcome several constraints. Implications: Transformation initiatives may build on existing features and resources, even as they overcome or depart from others. The Denver Health case study helps researchers identify positive antecedents to transformation initiatives, assess the success of such initiatives in terms of implementation progress and outcomes, and recognize complementary contributions of incremental and episodic changes. The study alerts practitioners to the importance of assuring that change efforts rest on solid organizational foundations.

Article-at-a-Glance Future Research Despite the gains to date, we need better understanding of practices for implementing and sustaining improvements in health care work environments and further study of organizational conditions affecting implementation of improvements. Practice Limiting work hours, improving schedules, and providing sleep hygiene training will help combat clinician fatigue. Hospital crowding can be reduced through systemwide improvement of patient flow and capacity management, coupled with management support, measurement, and reporting on crowding. Long-term solutions to nurse staffing shortfalls include process redesign to enhance efficiency. Improvement of organizational climate, human resource management, and interoccupational relations will also contribute to staff retention. Evidence-based enhancements to patient rooms and other physical features in hospitals contribute directly to safety and quality and also affect staff performance. Policy Landrigan and his colleagues call for external restrictions on residents' work shifts. Clarke examines prospects for mandated nursing-staff ratios. Public reporting on staffing, crowding, and other risks may incent change. Reporting and pay for performance require standardized measures of targeted conditions. Organizations promoting care quality can help spread safe work practices; they can also support collaborative learning and other strategies that may enhance implementation of improvements in work environments.

Many unintended and undesired consequences of Healthcare Information Technologies (HIT) flow from interactions between the HIT and the healthcare organization's sociotechnical system-its workflows, culture, social interactions, and technologies. This paper develops and illustrates a conceptual model of these processes that we call Interactive Sociotechnical Analysis (ISTA). ISTA captures common types of interaction with special emphasis on recursive processes, i.e., feedback loops that alter the newly introduced HIT and promote second-level changes in the social system. ISTA draws on prior studies of unintended consequences, along with research in sociotechnical systems, ergonomics, social informatics, technology-in-practice, and social construction of technology. We present five types of sociotechnical interaction and illustrate each with cases from published research. The ISTA model should further research on emergent and recursive processes in HIT implementation and their unintended consequences. Familiarity with the model can also foster practitioners' awareness of unanticipated consequences that only become evident during HIT implementation.

Organizational climate generally refers to staff members' perceptions of organizational features like decision making, leadership, and norms. It is widely acknowledged that these perceptions influence patient, employee, and system outcomes. However, there has been little consensus on how best to measure these important relationships. This article examines how organizational climate has been defined and measured in health services research and identifies factors most important in home healthcare delivery. Standardization of climate measures will facilitate the ultimate goal of translating results into evidence-based management practices to improve the quality of care delivery.

Despite waves of budget cuts and structural reorganizations, physicians in most of Europe have not been subject to managerial controls like those that have emerged in the United States and to a lesser degree in Britain. This paper examines one of the most dramatic instances in which physicians resisted managerial and governmental control and explains recent changes in this pattern. From 1982 through 1992, Dutch hospital specialists successfully blocked efforts by governmental regulators, insurers, and hospital managers to control the specialists' activities so as to reduce hospital costs, integrate care activities, and assure quality. Gradually the specialists began to lose their budgetary and operational autonomy and signed agreements with hospitals and insurers to integrate the specialists' fees into hospital budgets. These new fiscal arrangements increase the hospital managers' economic control over specialists and create possibilities for the enhancement of other types of managerial control. The organizational and political forces behind these changes are analyzed, along with their implications for future patterns of professional control in the Netherlands and for the integration of professional and managerial functions within Dutch hospitals.

Managed competition was introduced into the Israeli health care system with the enactment of the National Health Insurance (NHI) Law of 1995, which radically transformed health management organizations’ (HMO) regulatory and competitive environments. We conducted an in-depth, qualitative analysis of the strategies developed by two Israeli HMOs in response to this change, and developed the concept of a “strategic repertoire” to integrate diverse theories of organizational adaptation to environmental change. Although the responses of these organizations to managed competition were broadly comparable, they diverged from one another in important ways. Our analysis highlights how the interaction among organizational history, managerial choice, and environmental constraints creates divergence in organizational responses to national policy initiatives. Policy implications arising from the findings include ways of anticipating unintended consequences of policy initiatives, such as involving provider organizations in the structuring of reform, or simulating their response in advance, based on expert knowledge of their strategic repertoires; and the need to include mechanisms for obtaining feedback on organizational responses in the implementation of reform. This will facilitate the adjustment of program regulations and incentives in response to emerging practices.

Aims to understand the managerial implications of the perceptions hospital physicians and nurses hold toward the introduction of electronic medical records (EMRS). In‐depth interviews were used with 18 hospital physicians and eight nurses from several different hospital wards at a large government‐run, university‐affiliated hospital in Israel, where EMRs were gradually introduced over the last 20 years. Physicians identified six different domains of impact. Senior physicians, most of whom held managerial roles, tended to emphasise managerial outcomes and to view these as positively affecting their organisations. Junior doctors emphasised mostly negative occupational effects of the EMR on their work – including limits to professional autonomy, heavier administrative burdens, and reinforcement of existing professional hierarchies. Nurses identified different domains and saw benefits for quality and administration of patient care.

To help reduce gaps in knowledge of how context shapes improvement initiatives, we report a qualitative study of Lean implementation in 5 divergent organizations. Our conceptual model distinguishes...

Sweden was an important pioneer of market-oriented reform in publicly funded health-care systems. Yet by the mid-1990s the county councils, which fund and manage most health-care, had substantially scaled back reforms based on provider competition while continuing to constrain health budgets. As policy makers faced new issues, they turned increasingly to longer-term and more cooperative contracts to define relations between hospitals and the county councils. Growing regionalization of government and hospital mergers further reconfigured acute care and limited opportunities for competition between hospitals. We seek to explain this reorientation of market-oriented reforms between 1989 and 1996 in terms of shifts in the positions taken by powerful policy actors, and in particular by county council politicians. During this period, elections moved liberal and conservative politicians, who were the most enthusiastic supporters of market-oriented reform, in and out of control of most county governments. Meanwhile many Social Democratic politicians gradually turned from initial support of competitive reform toward opposition. Politicians and county administrators from all parties were particularly concerned about controlling health expenditures during a period of recession. In addition, the public, politicians in the counties and municipalities, and health professionals resisted steps that threatened health sector employment and would have allowed market mechanisms, rather than governments, to determine the prices and distribution of health services. During the years under study Sweden's market-oriented reforms followed a course of development similar to that taken by other management and policy fashions (Abrahamson E. Management fashion, Academy of Management Review 1996;21: 254-85). At first the reforms enjoyed uncritical support by a broad spectrum of stakeholders. Gradually participants in the reform process recognized inherent tensions among the goals of the reform, conflicts between reform programs and fundamental social and political values, unrealistic assumptions about the effects of competition, technical and organizational obstacles to implementation, and threats to interest groups. Since 1998, there have been indications that Sweden may be entering yet another stage of experimentation with market-oriented reform.