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GoalThis study explored the use of a Lean daily management system (DMS) for COVID-19 response and recovery in U.S. hospitals and health systems. Originally developed in manufacturing, Lean is an evidence-based approach to quality and process improvement in healthcare. Although Lean has been studied in individual hospital units and outpatient practices, it has not been examined as a whole system response to crisis events.MethodsWe conducted qualitative interviews with 46 executive leaders, clinical leaders, and frontline staff in four hospitals and health systems across the United States. We developed a semistructured interview guide to understand DMS implementation in these care delivery organizations. As interviews took place 6-8 months following the onset of the pandemic, a subset of our interview questions centered on DMS use to meet the demands of COVID-19. Based on a deductive approach to qualitative analysis, we identified clusters of themes that described how DMS facilitated rapid system response to the public health emergency.Principal findingsThere were many important ways in which U.S. hospitals and health systems leveraged their DMS to address COVID-19 challenges. These included the use of tiered huddles to facilitate rapid communication, the creation of standard work for redeployed staff, and structured problem-solving to prioritize new areas for improvement. We also discovered ways that the pandemic itself affected DMS implementation in all organizations. COVID-19 universally created greater DMS visibility by opening lines of communication among leadership, strengthening measurement and accountability, and empowering staff to develop solutions at the front lines. Many lessons learned using DMS for crisis management will carry forward into COVID-19 recovery efforts. Lessons include expanding telehealth, reactivating incident command systems as needed, and efficiently coordinating resources amid potential future shortages.Practical applicationsOverall, the Lean DMS functioned as a robust property that enabled quick organizational response to unpredictable events. Our findings on the use of DMS are consistent with organizational resilience that emphasizes collective sense-making and awareness of incident status, team decision-making, and frequent interaction and coordination. These features of resilience are supported by DMS practices such as tiered huddles for rapid information dissemination and alignment across organizational hierarchies. When used in conjunction with plan-do-study-act methodology, huddles provide teams with enhanced feedback that strengthens their ability to make changes as needed. Moreover, gaps between work-as-imagined (how work should be done) and work-as-done (how work is actually done) may be exacerbated in the initial chaos of emergency events but can be minimized through the development of standard work protocols. As a facilitator of resilience, the Lean DMS may be used in a variety of challenging situations to ensure high standards of care.

Despite the rapid spread of Lean management in health care, few organizations have achieved measurable overall performance improvements with Lean. What differentiates these organizations from those that struggle with realizing the potential benefits of Lean management is unclear. In this qualitative study we explore measuring the impact of Lean and the recommended practices for achieving measurable performance improvements with Lean in health care organizations.Informed by preliminary quantitative results from analyses of high- and low-performing Lean hospitals, we conducted 17 semi-structured interviews with Lean health care experts on the Lean principles and practices associated with better performance. We conducted qualitative content analyses of the interview transcripts based on grounded theory and linking to core principles and practices of the Lean management system.The qualitative data revealed 3 categories of metrics for measuring the impact of Lean: currently used institutional measures, measures tailored to Lean initiatives, and population-level measures. Leadership engagement/commitment and clear organizational focus/prioritization/alignment had the highest weighted averages of success factors. The lack of these 2 factors had the highest weighted averages of biggest barriers for achieving measurable performance improvements with Lean implementation.Leadership engagement and organizational focus can facilitate achieving the organization's performance improvement goals, whereas their absence can considerably hinder performance improvement efforts. Many different approaches have been used to quantify the impact of Lean, but currently used institutional performance measures are preferred by the majority of Lean experts.

In this chapter, we identify three distinct transformational performance improvement (TPI) approaches commonly used to redesign work processes in health care organizations. We describe the unique components or tools that each approach uses to improve the delivery of health services. We also summarize what is empirically known about the effectiveness of each TPI approach according to systematic reviews and recent studies published in the peer-reviewed literature. Based on examination of this research, we discuss what knowledge is still needed to strengthen the evidence for whole system transformation. This involves the use of conceptual frameworks to assess and guide implementation efforts, and facilitators and barriers to change as revealed in a recent evaluation of one major initiative, the Lean Enterprise Transformation (LET) at the Veterans Health Administration. The analysis suggests ways in which TPI facilitators can be developed and barriers reduced to improve the effectiveness and sustainability of quality initiatives. Finally, we discuss appropriate study designs to evaluate TPI interventions that may strengthen the evidence for their effectiveness in real world practice settings.

BACKGROUND AND OBJECTIVES: The United States has an under-performing healthcare system on both cost and quality criteria in comparison with other developed countries. One approach to improving system performance on both cost and quality is to use the Lean management system based on the Shingo principles originally developed by Toyota in Japan. Our objective is to examine the association between hospital use of the Lean management system and evidence-based or recommended quality improvement care management processes. METHODS: A cross sectional analysis of data from 223 hospitals that responded to both the 2017 National Survey of Healthcare Organizations and Systems (NSHOS) and the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals (NSL) was conducted. RESULTS: Controlling for hospital organizational and market characteristics, the number of years doing Lean was positively associated with use of electronic health record-based decision support, use of quality-focused information management, use of evidence-based guidelines, and support for care transitions at the p

Background and objectives Lean management in health care organizations attempts to empower staff to generate continuous improvement through incremental but regular improvements in work processes. However, because of the increasing pressure on health care organizations to substantially improve quality of care and patient outcomes while containing costs in the relatively short term, many health care leaders are looking for ways to achieve large breakthrough improvements in their organization's performance. The objective of this research is to understand whether and how Lean management can be used to achieve breakthrough improvements in performance. Methods This study used grounded theory and content analysis of in-depth, semistructured interviews with 10 nationally recognized experts in the use of Lean management in health care organizations. The 10 participants constitute a purposive sample of experts with in-depth understanding of the strengths and limitations of Lean management in health care organizations. Results Two out of 10 participants defined breakthrough improvement as a major change in a performance metric; 2 participants defined it as a fundamental redesign in a process or service; the remaining 6 participants defined breakthrough improvement as having both these characteristics. The extent to which participants believed Lean was an effective means for achieving breakthrough improvement in performance was related to how they defined breakthrough improvement. The 2 participants who defined breakthrough improvement as a significant change in a performance metric believed Lean methods alone were sufficient. The 2 participants who defined breakthrough improvement to be a fundamental redesign tended not to view Lean alone as an effective approach. Rather, they, and the 6 participants who defined breakthrough improvement as having both change-in-metric and process redesign characteristics, viewed human-centered design thinking as the primary or important complementary approach to achieving breakthrough improvement. Participants identified resources, culture change, and leadership commitment beyond what would be required to achieve incremental improvement as the main facilitators and barriers to achieving breakthrough improvements. Conclusion This research reveals some differences in experts' definitions of breakthrough improvement, and illuminates the value of human-centered design thinking, alone or as a complement to Lean management, in achieving breakthrough improvement in health care organizations. Most of our expert participants agreed that supplementing Lean management methods with the contributions of innovation design and investing significant resources, strengthening the organizational culture to support the necessary changes, and providing stronger leadership commitment to the effort are important facilitators for achieving breakthroughs in organizational performance.

Lean management is growing in popularity in the healthcare sector worldwide, yet healthcare organizations are struggling with assessing the maturity of their Lean implementation and monitoring its change over time. Most existing methods for such assessments are time consuming, require site visits by external consultants, and lack frontline involvement. The original Lean Healthcare Implementation Self-Assessment Instrument (LHISI) was developed by the Center for Lean Engagement and Research (CLEAR), University of California, Berkeley as a Lean principles-based survey instrument that avoids the above problems. We validated the original LHISI in the context of Finnish healthcare. Background Lean management is growing in popularity in the healthcare sector worldwide, yet healthcare organizations are struggling with assessing the maturity of their Lean implementation and monitoring its change over time. Most existing methods for such assessments are time consuming, require site visits by external consultants, and lack frontline involvement. The original Lean Healthcare Implementation Self-Assessment Instrument (LHISI) was developed by the Center for Lean Engagement and Research (CLEAR), University of California, Berkeley as a Lean principles-based survey instrument that avoids the above problems. We validated the original LHISI in the context of Finnish healthcare. Methods The original HISI survey was sent over a secure organizational email system to the over 26,000 employees of the Hospital District of Helsinki and Uusimaa in March 2020. The data were randomly split with one part used to carry out an exploratory factor analysis (EFA), and the other for testing the resulting model using confirmatory factor analysis (CFA). Results A total of 6073 employees responded to the LHISI survey, for an overall response rate of 23%. The results indicated that the 43 items used in the original LHISI can be reduced to 25 items, and these items measure a five-dimensional model of the progress of Lean implementation: leadership, commitment, standard work, communication, and daily management system. In comparison with a single-factor model, the fit measures for the 5-factor model were better: smaller X-2, larger comparative fit index (CFI), smaller root mean square error of approximation (RMSEA), and smaller standardized root mean square residual (SRMR). Conclusions The 25 item LHISI is valid and feasible to use in the context of Finnish healthcare. The LHISI allows the organization to self-monitor the progress of its Lean implementation and provides the leadership with actionable knowledge to guide the path towards Lean maturity across the organization. Our findings encourage further studies on the adoption and validation of the LHISI in healthcare organizations worldwide.

Background Health-care organizations around the world are striving to achieve transformational performance improvement, often through adopting process improvement methodologies such as lean management. Indeed, lean management has been implemented in hospitals in many countries. But despite a shared methodology and the potential benefit of benchmarking lean implementation and its effects on hospital performance, cross-national lean benchmarking is rare. Health-care organizations in different countries operate in very different contexts, including different health-care system models, and these differences may be perceived as limiting the ability of improvers to benchmark lean implementation and related organizational performance. However, no empirical research is available on the international relevance and applicability of lean implementation and hospital performance measures. To begin understanding the opportunities and limitations related to cross-national benchmarking of lean in hospitals, we conducted a cross-national case study of the relevance and applicability of measures of lean implementation in hospitals and hospital performance. Methods We report an exploratory case study of the relevance of lean implementation measures and the applicability of hospital performance measures using quantitative comparisons of data from Hospital District of Helsinki and Uusimaa (HUS) Helsinki University Hospital in Finland and a sample of 75 large academic hospitals in the USA. Results The relevance of lean-related measures was high across the two countries: almost 90% of the items developed for a US survey were relevant and available from HUS. A majority of the US-based measures for financial performance (66.7%), service provision/utilization (100.0%) and service provision/care processes (60.0%) were available from HUS. Differences in patient satisfaction measures prevented comparisons between HUS and the USA. Of 18 clinical outcome measures, only four (22%) were not comparable. Clinical outcome measures were less affected by the differences in health-care system models than measures related to service provision and financial performance. Conclusions Lean implementation measures are highly relevant in health-care organizations operating in the USA and Finland, as is the applicability of a variety of performance improvement measures. Cross-national benchmarking in lean healthcare is feasible, but a careful assessment of contextual factors, including the health-care system model, and their impact on the applicability and relevance of chosen benchmarking measures is necessary. The differences between the US and Finnish health-care system models is most clearly reflected in financial performance measures and care process measures.

BACKGROUND Given pressures to control costs and improve quality of care, one of the most prevalent transformational performance improvement approaches in health care is Lean management. However, the roles of support functions such as human resource (HR), finance, and information technology (IT) in Lean management and the relationships of these support functions with performance are unknown. PURPOSE The aim of this study was to examine the relationships between the HR, finance, and IT functions, overall Lean implementation, and self-reported performance improvement in hospitals that have implemented Lean. METHODOLOGY/APPROACH Data from a national survey of Lean in U.S. hospitals (N = 1,222; 847 reported using Lean) were analyzed using multivariable regression and bootstrapped mediation analysis. The extent to which HR, finance, and IT functions support Lean management was measured using indices including six, three, and six items respectively. Lean implementation was measured by the number of units doing Lean (up to 29) and by a four-level self-reported maturity scale. Performance improvement was measured using an index of self-reported achievements (ranging from 0 to 16). RESULTS There were significant positive associations between Lean HR, finance, and IT functions and self-reported performance impact (controlling for organizational and market variables). Tests of mediation indicated that the associations of HR, finance, and IT functions with self-reported performance were significantly mediated by the number of Lean units (mediated proportion ranging from 40% to 73%), and HR function was also mediated by self-reported maturity (61% mediated). There were no moderating effects. CONCLUSION HR, finance, and IT functions are positively associated with self-reported Lean impact on performance and primarily explained by the overall degree of Lean implementation. PRACTICE IMPLICATIONS Efforts to align HR, finance, and IT functions with overall Lean implementation can help to ensure that frontline caregivers and managers have the data and skills required to meet transformational improvement goals.

The Lean management system is being adopted and implemented by an increasing number of US hospitals. Yet few studies have considered the impact of Lean on hospitalwide performance.A multivariate analysis was performed of the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals and 2018 publicly available data from the Agency for Healthcare Research and Quality and the Center for MedicareMedicaid Services on 10 quality/appropriateness of care, cost, and patient experience measures.Hospital adoption of Lean was associated with higher Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores (b = 3.35, p0.0001) on a scale of 100-300 but none of the other 9 performance measures. The degree of Lean implementation measured by the number of units throughout the hospital using Lean was associated with lower adjusted inpatient expense per admission (b = -38.67; p0.001), lower 30-day unplanned readmission rate (b = -0.01, p0.007), a score above the national average on appropriate use of imaging-a measure of low-value care (odds ratio = 1.04, p0.042), and higher HCAHPS patient experience scores (b = 0.12, p0.012). The degree of Lean implementation was not associated with any of the other 6 performance measures.Lean is an organizationwide sociotechnical performance improvement system. As such, the actual degree of implementation throughout the organization as opposed to mere adoption is, based on the present findings, more likely to be associated with positive hospital performance on at least some measures.

RESEARCH OBJECTIVE: Lean implementation assessment is needed to understand the depth and breadth of Lean deployment and guide organizations in strengthening Lean implementation and its potential to improve organizational performance. To assist health care leaders to understand the extent to which Lean management has been implemented in their organizations, we developed the Lean Healthcare Implementation Self‐Assessment Instrument (LHISI), a 34‐item survey instrument that assesses Lean implementation across six dimensions. STUDY DESIGN: Following a review of extant measures of Lean implementation, an initial list of 101 items was compiled and reviewed by Lean implementation experts, reflecting behaviors linked to 14 principles of Lean management from the Shingo and 4P models of Lean. Two rounds of item selection surveys were completed by health care managers and clinicians to identify the most important items, which were included in LHISI version 1 (V1). Managers and clinicians in 7 different organizations completed two rounds of V1 pilot testing used to perform test‐retest analyses, exploratory factor analysis (EFA), and other statistical tests to develop V2. Finally, managers and clinicians at two large teaching hospitals pilot tested V2, and their responses were divided into half and used for EFA and confirmatory factor analysis (CFA), respectively. POPULATION STUDIED: Item selection and pilot testing surveys were completed by managers and clinicians in seven health care organizations currently implementing Lean management. The two rounds of item selection included 36 and 39 respondents; V1 pilot testing included 232 respondents (including 34 retests); and V2 pilot testing included 914 respondents. PRINCIPAL FINDINGS: Expert review and two rounds of item selection testing reduced the number of survey items from 101 to the 48 items included in V1. Each item reflects an important core principle of Lean (eg, In my unit/department, work processes are standardized; across my hospital/clinic, leaders at all levels create a safe environment for exposing problems; and in my unit/department, frontline staff use visual displays to understand their unit’s performance). V1 pilot testing analyses suggested removal of 5 items: 2 items did not load on a factor in exploratory factor analysis, and 3 items had insufficient test‐retest reliability (the remaining items had Pearson’s r 0.72‐0.85). Consequently, LHISI V2 included 43 items, and the 914 responses were randomly divided and used for EFA and CFA. EFA demonstrated six underlying factors encompassing 34 items (9 items did not fit well with any factor): organizational culture (10 items), commitment to Lean (7 items), standard work (5 items), huddles (4 items), unit culture (4 items), and visual management (4 items). Each of the subscales demonstrates good internal consistency, with Cronbach alphas ranging from .89 to .97. CFA model fit comparisons supported the above six‐factor model over single factor and seven‐factor models. CONCLUSIONS: The 34‐item LHISI demonstrates good content validity, internal consistency, test‐retest reliability, and appropriate factor clusters. IMPLICATIONS FOR POLICY OR PRACTICE: The LHISI provides an accessible way for health care leaders to assess Lean implementation in their organization and to identify targets for improvement. Ongoing research will further explore the characteristics of the instrument, including the relationship between LHISI scores and performance.

BACKGROUND Despite being adopted by a large number of hospitals, the relationship between Lean management and hospital performance is mixed and not well understood. PURPOSE We examined the relationships between Lean and hospital financial performance, patient outcomes, and patient satisfaction in a large national sample of hospitals, controlling for relevant organizational and market factors. METHODOLOGY/APPROACH A mixed effects linear regression analysis was performed to assess the relationships between adoption of Lean and 10 measures of hospital performance using data from 1,152 hospitals that responded to the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals. Hospital performance, organizational, and market data over the period 2011-2015 come from the 2015 American Hospital Association Annual Hospital Survey and the respective annual Centers for Medicare & Medicaid Services (CMS) Medicare Cost Report, CMS Hospital Compare, CMS MEDPAR, and the CMS Hospital Service Area File. RESULTS Lean adoption was significantly associated at alpha < .05, with lower Medicare spending per beneficiary (b = -.005, p = .027). None of the other nine associations were statistically significant, although eight of them were in the predicted direction. CONCLUSION Lean adoption is not associated with most measures of hospital performance. It is likely Lean implementation varies greatly across hospitals. Future research should examine the relationships among the various dimensions of Lean implementation and performance. PRACTICE IMPLICATIONS If Lean management is to contribute to hospital performance improvement, leaders must be highly cognizant of what "adoption of Lean" actually means in their hospital. Although limited, single-unit Lean initiatives in an emergency room or other patient care unit may improve performance on some unit-specific measures, improvement on hospital-wide measures of performance requires a broad, sustained commitment to the implementation of Lean practices and tools.

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

EXECUTIVE SUMMARY Many public hospitals have adopted Lean management methodology, but little is known about the extent of Lean adoption or the relationship between Lean adoption and hospital performance. Using data from the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals, linked with data from the American Hospital Association 2015 Annual Hospital Survey and 2015 Centers for Medicare & Medicaid Services data on hospital performance, we compare public hospitals with nonprofit and for-profit hospitals on the rate of Lean adoption and the extent of Lean implementation. We also assess the associations between Lean adoption by the end of 2014 and measures of public hospital financial performance, patient outcomes, and patient satisfaction measured in 2015.Among the 288 public hospitals that responded to the survey, 54.2% reported that they had adopted Lean. The average length of time of Lean implementation was 4.58 years. The mean number of units in which Lean was implemented was 11.9 out of 29 possible hospital units, with the emergency department (ED) being the unit in which Lean was most frequently implemented. The most common Lean practices used were daily huddles, plan-do-study-act cycles, visual management, and use of standard work. Lean adoption by 2014 was significantly associated in the direction predicted with earnings before interest, taxes, depreciation, and amortization margin (b = .042, p < .020) and percentage of patients leaving the ED without being seen (b = -0.610, p < .068). No significant associations were found between Lean adoption and patient outcomes or patient satisfaction.

The integration of health care services is intended to improve the continuity, quality and efficiency of care provided to patients. This is a challenging goal and presumes that there is much about the current health care system that needs improvement. Health maintenance organisations (HMOs) provide a continuum of services including disease prevention, primary, secondary and tertiary acute care services, in exchange for a fixed membership fee per member per month. Community Care Retirement Communities (CCRC) provides a package of services, including housing, health care, and social services, to older adults. The chapter examines the efforts in the United States and the United Kingdom to integrate health services. It is apparent that fully integrated systems are more rare than appears at first glance. Thus the much more challenging task of developing fully integrated systems may be reserved for those sub-populations with high levels of medical need or special circumstances.

Background The accountable care organization (ACO) is a new type of health care organization incentivized to improve quality of care, improve population health, and reduce the cost of care. An ACO's success in meeting these objectives depends greatly upon its ability to improve patient care management. Numerous studies have found relational coordination to be positively associated with key measures of organizational performance in health care organizations, including quality and efficiency. Purpose The purpose of this paper is twofold: (a) identify the extent to which ACO leaders are aware of the dimensions of relational coordination, and (b) identify the ways these leaders believe the dimensions influenced care management practices in their organization. Methodology/approach We performed content analysis of interviews with managerial and clinical leaders from a diverse group of 11 ACOs to assess awareness of relational coordination and identify the ways that dimensions of relational coordination were perceived to influence development of care management practices. Findings ACO leaders mentioned four relational coordination dimensions: shared goals, frequency of communication, timeliness of communication, and problem solving communication. Three dimensions - shared knowledge of team members' tasks, mutual respect, and accuracy of communication - were not mentioned. Our analysis identified numerous ways leaders believed the four mentioned dimensions contributed to the development of care management, including contributions to standardization of care, patient engagement, coordination of care, and care planning. Discussion We propose two hypotheses for future research on relational coordination and care management. Practice implications If relational coordination is to have a beneficial influence on ACO performance, organizational leaders must become more aware of relational coordination and its various dimensions and become cognizant of relational coordination's influence on care management in their ACO. We suggest a number of means by which ACO leaders could become more aware of relational coordination and its potential effects.

Purpose: Delivering comprehensive patient portals in fragmented delivery systems depends on coordination among a network of healthcare organizations. Inter-organizational coordination is fraught with challenges, mainly due to a lack of organizational, technological, and geographical proximity between network participants. This paper assesses the extent to which application of Relational Coordination Theory (RCT) can ameliorate these challenges. Approach: We conducted a conceptual analysis of the usefulness of RCT and the applicability of the Relational Model of Organizational Change to patient portal networks. Findings: Relational coordination can mitigate challenges caused by lack of organizational and technological proximity among participants in a patient portal network. The Relational Model of Organizational Change is useful to improve relational coordination. However, some organization redesign interventions proposed in the Model may not be directly applicable to patient portal networks due to lack of geographical proximity among network participants. Conclusion: We suggest three propositions regarding the relationships among relational coordination, organizational and technological proximity, and cost of coordination in an inter-organizational portal network. If future research provides empirical support for these propositions and identifies appropriate adaptations of the Relational Model of Organizational Change for inter-organizational contexts, portal network leaders should strive to strengthen relational coordination in their networks.

Background Use of patient portals may contribute to improved patient health and experiences and better organizational performance. In the Netherlands, patient portals have gained considerable attention in recent years, as evidenced by various policy initiatives and practical efforts directed at developing portals. Due to the fragmented setup of the Dutch healthcare system patient portals that give patients access to information and services from across their providers are developed in inter-organizational collaboration. Objective The objective of this paper is to identify and describe the types of collaborations, or networks, that have been established to develop patient portals in the Netherlands. Understanding the characteristics of these networks as well as the development of their respective portals enables us to assess the enabling and constraining effects of different network types on patient portal initiatives. Methods We used qualitative methods including interview and documents analysis. In a first step, we interviewed eighteen experts and reviewed relevant national policy and strategy documents. Based on this orientation, we selected three networks we deemed to be representative of inter-organizational efforts to develop Dutch patient portals in 2012. In a second step, we interviewed twelve representatives of these patient portal networks and collected documents related to the portals. We applied content analytic techniques to analyze data from the three cases. Results The three studied networks differed in their number and diversity of actors, the degree to which these actors were mutually dependent, the degree to which network governance was decentralized, and the dynamics of the network structures. We observed that the portals developed in networks displaying the highest degree of these characteristics experienced most difficulties associated with developing patient portals – such as achieving interoperability, successful implementation, regulatory complaisance, and financial sustainability. Yet, at the same time, the portals developed in these networks may hold the highest functionality to patients, since they can consolidate information and services from a broad array of health service providers. Conclusions The early empirical evidence provided here indicates that effective development of patient portals begs a tradeoff between envisioned functionality and ease of development.

Background Care for patients with chronic conditions often requires coordination between multiple physicians and delivery sites. Electronic Health Record (EHR) use could improve care quality and efficiency in part by facilitating care coordination. Objective We examined the association between EHR use and clinician perceptions of care coordination for patients transferred across clinicians and delivery sites. Research design Repeated surveys of primary care clinicians during the staggered implementation of an outpatient EHR (2005-2008), followed by an integrated inpatient EHR (2006-2010). We measured the association between EHR use stages (no use, outpatient EHR only, and integrated inpatient-outpatient EHR) and care coordination using logistic regression, adjusting for clinician characteristics, study year, and medical center. Subjects Adult primary care clinicians in a large Integrated Delivery System. Measures Three measures of clinician-reported care coordination for patient care transferred across clinicians (eg, from specialist to primary care team) and across delivery sites (eg, from the hospital to outpatient care). Results Outpatient EHR use was associated with higher reports of access to complete and timely clinical information and higher agreement on clinician roles and responsibilities for patients transferred across clinicians, but not for patients transferred across delivery sites. Use of the integrated outpatient-inpatient EHR was associated with higher reports of access to timely and complete clinical information, clinician agreement on the patient's treatment plan for patients transferred across delivery sites, and with all coordination measures for patients transferred across clinicians. Conclusion Use of an integrated EHR with health information exchange across delivery settings improved patient care coordination.

To be successful, accountable care organizations (ACOs) must effectively manage patient care. Health information technology (HIT) can support care delivery by providing various degrees of coordination. Few studies have examined the role of HIT functionalities or the role of different levels of coordination enabled by HIT on care management processes. We examine HIT functionalities in ACOs, categorized by the level of coordination they enable in terms of information and work flow, to determine which specific HIT functionalities and levels of coordination are most strongly associated with care management processes. Retrospective cross-sectional analysis was done using 2012 data from the National Survey of Accountable Care Organizations. HIT functionalities are categorized into coordination levels: information capture, the lowest level, which coordinates through standardization; information provision, which supports unidirectional activities; and information exchange, which reflects the highest level of coordination allowing for bidirectional exchange. The Care Management Process index (CMP index) includes 13 questions about the extent to which care is planned, monitored, and supported by providers and patients. Multiple regressions adjusting for organizational and ACO contractual factors are used to assess relationships between HIT functionalities and the CMP index. HIT functionality coordinating the most complex interdependences (information exchange) was associated with a 0.41 standard deviation change in the CMP index (β = .41, p < .001), but the associations for information capture (β = −.01, p = .97) and information provision (β = .15, p = .48) functionalities were not significant. The current study has shed some light on the relationship between HIT and care management processes by specifying the coordination roles that HIT may play and, in particular, the importance of information exchange functionalities. Although these represent early findings, further research can help policy makers and clinical leaders understand how to prioritize HIT development given resource constraints.

Objective To examine how patient portals contribute to health service delivery and patient outcomes. The specific aims were to examine how outcomes are produced, and how variations in outcomes can be explained. Methods We used a realist review method, which aims to describe how ‘an intervention works, for whom, and in what circumstances’ by analyzing patterns between context, mechanism, and outcomes. We reviewed 32 evaluation studies of patient portals published since 2003. Results The reviewed evaluations indicate that as a complement to existing health services, patient portals can lead to improvements in clinical outcomes, patient behavior, and experiences. Four different mechanisms are reported to yield the reported outcome improvements. These are patient insight into personal health information, activation of information, interpersonal continuity of care, and service convenience. The vast majority of evaluations were conducted in integrated health service networks in the USA, and we detected no substantial variation in outcomes across these networks. Discussion and conclusions Patient portals may impact clinical outcomes and health service delivery through multiple mechanisms. Given the relative uniformity of evaluation contexts, we were not able to detect patterns in how patient portals work in different contexts. Nonetheless, it appears from the overwhelming proportion of patient portal evaluations coming from integrated health service networks, that these networks provide more fertile contexts for patient portals to be effective. To improve the understanding of how patient portals work, future evaluations of patient portals should capture information about mechanisms and context that influence their outcomes.

A growing number of Americans are living with chronic medical conditions and often require medical care that bridges multiple delivery sites, such as hospitals and primary care clinics (Partnership for Solutions 2004; Bodenheimer, Chen, and Bennett 2009; Schoen et al. 2009; Anderson 2010; Thorpe, Ogden, and Galactionova 2010). Effective coordination is necessary to ensure high-quality care for these patients. In part to promote greater care coordination, the American Recovery and Reinvestment Act (ARRA) of 2009 allocated $27 billion to encourage adoption and meaningful use of electronic health records (EHRs) in the United States (Blumenthal 2010b; Blumenthal and Tavenner 2010). Communication of clinical information for coordination of care across delivery sites is an explicit requirement for “meaningful use” payments under ARRA (Blumenthal 2010a). Other health care innovations such as bundled payments, accountable care organizations, and patient centered medical homes aim to improve care quality in part through facilitating care coordination and a greater reliance on team-based care (Rittenhouse and Shortell 2009; Blumenthal and Tavenner 2010; Shortell, Casalino, and Fisher 2010). Given the ongoing reforms targeting the organization and financing of health care, and sizable federal investment in EHRs, it is important to understand how the organizational environment can influence the EHR effect on various outcomes, including care coordination. The shared use of an EHR across hospitals, specialist and primary care practices, and other provider organizations offers great potential to improve coordination by enabling access to comprehensive, current patient information each time a patient is seen by clinicians. EHRs also provide tools to monitor a patient’s health status and intervene promptly when necessary. However, effective use of the information and tools made available by an EHR requires active communication and teamwork between clinicians. In other words, having the basic infrastructure of an integrated delivery system or shared EHR may be insufficient to improve the delivery of care if clinicians do not make full use of the information or fail to use it when working with other clinicians. There is limited research on the effects of EHR use on care coordination (Graetz et al. 2009; O’Malley et al. 2009) and no evidence on how organizational factors may change this effect. For this study, we focus on the coordination of care across delivery sites, such as when patients leave hospitals and re-enter primary care. These transitions represent a timely area of policy and clinical interest, during which prior studies have found high rates of errors (Coleman et al. 2006). We examined the combined effect of an integrated outpatient–inpatient certified EHR and team cohesion on clinician ratings of care coordination across delivery sites in a prepaid IDS. We used survey data from primary care clinicians collected in three different years (2005, 2006, and 2008), during the staggered implementation of a commercially available, integrated EHR system (2005–2010). We hypothesized that the use of the integrated EHR would result in improvements in all reported measures of care coordination and that the magnitude of the association would be greater for clinicians working in primary care teams with higher cohesion.

EXECUTIVE SUMMARYHospitals with a challenging payer mix (CPM)-high proportions of uninsured and Medicaid patients and a low proportion of commercially insured patients-are an important source of care for low-income, uninsured people. Achieving profitability is difficult for CPM hospitals. From 2005 through 2008, only one-third of 67 CPM hospitals in California reported positive total margins. In-depth group interviews were completed with the management leadership teams of a diverse group of five profitable CPM hospitals to identify the management strategies and practices that the hospitals' leadership teams credited for their financial success. Twelve management policy and practice topics were identified. Four of the policies and practices that managers identified involve organizational actions to increase hospital revenue or operational efficiency. These factors are consistent with those identified in previous research. However, managers also identified eight factors not previously revealed in research on hospital profitability, including management policies and practices that establish the organizational culture, workforce, relationships, monitoring systems, and governance necessary to ensure that hospital employees and affiliated physicians support and successfully implement organizational actions necessary to achieve profitability.INTRODUCTIONFor many years, there has been widespread concern about the financial viability of our nation's safety-net hospitals (Cunningham, Bazzoli, and Katz 2008; Bazzoli et al. 2006; Bazzoli et al. 2005; Cunningham 2007). These public and not-for-profit hospitals are a major source of care for lowincome, uninsured, and underinsured people. Although there is no universally accepted definition of a safety-net hospital, generally such hospitals are characterized by a challenging payer mix (CPM), which we have defined as the combination of (a) a high percentage of Medicaid (Medi-Cal in California) patients; (b) high uncompensated care as a percentage of expenses1; and (c) a low percentage of commercially insured patients in relation to other hospitals (NAPH 2010). Typically, it is difficult for hospitals witfi these three characteristics to achieve financial profitability, because the revenue received from commercially insured patients may be insufficient to make up for the losses incurred from providing services to uninsured patients and patients covered by lower-paying Medicaid and Medicare programs (Felland et al. 2010). Since the beginning of the recession in 2007, rising unemployment and decreasing tax revenues have increased the challenges CPM hospitals face (Holahan and Garrett 2009). The 2009 American Recovery and Reinvestment Act (ARRA) helped maintain the financial viability of safety-net hospitals (Felland et al. 2010). However, even with the support provided by ARRA safety-net providers reported more financial strain in 2008 and 2009 than in previous years (Felland et al. 2010).The literature suggests that many factors that affect hospital profitability are beyond managers' immediate control, including a given hospital's geographic location, extent of health insurance coverage in the primary service area, ownership status, teaching status, amount of competition in the market (Younis, Rice, and Barkoulas 2001; Younis and Forgione 2005; Gapenski, Vogel, and Langland-Orban 1993), and penetration of managed care (Resnick et al. 2005). However, previous studies have also identified a number of factors that hospital management can influence to a greater or lesser extent (in collaboration with others, including nurses and physicians), including factors such as adjusted number of employees, length of stay, bed capacity, occupancy rate, volume of Medicare and Medicaid patients (Younis, Rice, and Barkoulas 2001; Younis and Forgione 2005), surgeon productivity (Resnick et al. 2005), capital structure (Das 2009), supply of physicians in the local market (Kim 2010), amount of nonoperating revenue (net income from sources not directly connected to patient care) (Schuhmann 2010), and market share (McCue 2007). …

Evidence of the impact electronic health records (EHRs) have on clinical outcomes remains mixed. The impact of EHRs likely depends on the organizational context in which they are used. This study focuses on one aspect of the organizational context: cohesion of primary care teams. We examined whether team cohesion among primary care team members changed the association between EHR use and changes in clinical outcomes for patients with diabetes.Retrospective longitudinal study.We combined provider-reported primary care team cohesion with lab values for patients with diabetes collected during the staggered EHR implementation (2005-2009). We used multivariate regression models with patient-level fixed effects to assess whether team cohesion levels changed the association between outpatient EHR use and clinical outcomes for patients with diabetes. Subjects were comprised of 80,611 patients with diabetes, in whom we measured changes in glycated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDL-C).For A1C, EHR use was associated with an average decrease of 0.11% for patients with higher-cohesion primary care teams compared with a decrease of 0.08% for patients with lower-cohesion teams (difference = 0.02% in A1C; 95% CI, 0.01%-0.03%). For LDL-C, EHR use was associated with a decrease of 2.15 mg/dL for patients with higher-cohesion primary care teams compared with a decrease of 1.42 mg/dL for patients with lower-cohesion teams (difference = 0.73 mg/dL; 95% CI, 0.41-1.11 mg/dL).Patients cared for by higher cohesion primary care teams experienced modest but statistically significantly greater EHR-related health outcome improvements, compared with patients cared for by providers practicing in lower cohesion teams.

Understanding the factors that affect physicians' job satisfaction is important not only to physicians themselves, but also to patients, health system managers, and policy makers. Physicians represent the crucial resource in health-care delivery. In order to enhance efficiency and quality in health care, it is indispensable to analyse and consider the motivators of physicians. Physician job satisfaction has significant effects on productivity, the quality of care, and the supply of physicians. The purpose of our study was to assess the associations between work-related monetary and non-monetary factors and physicians' work satisfaction as perceived by similar groups of physicians practicing at academic medical centres in Germany and the U.S.A., two countries that, in spite of differing health-care systems, simultaneously experience problems in maintaining their physician workforce. We used descriptive statistics, factor and correlation analyses to evaluate physicians' responses to a self-administered questionnaire. Our study revealed that overall German physicians were less satisfied than U.S. physicians. With respect to particular work-related predictors of job satisfaction we found that similar factors contributed to job satisfaction in both countries. To improve physicians' satisfaction with working conditions, our results call for the implementation of policies that reduce the time burden on physicians to allow more time for interaction with patients and colleagues, increase monetary incentives, and enhance physicians' participation in the development of care management processes and in managerial decisions that affect patient care.

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

In recent years, spurred by developments in evidence-informed medicine, a movement to strengthen evidence-informed managerial decision making in healthcare organizations has emerged in the United States and in other countries. The drivers of this movement include demands by payers and consumer groups for improved quality of care, increased operational efficiency, and greater accountability from healthcare organizations. But numerous barriers to managers' use of evidence in decision making exist, including time pressures, perceived threats to autonomy, preference for colloquial knowledge based on individual experiences, difficulty accessing the relevant evidence base, reliance on external consultants (and others) to determine the quality of the information, and lack of resources. To help managers overcome these barriers, we developed the Informed Decisions Toolbox. It provides tools to help managers efficiently perform the six key steps in the evidence-informed approach to decision making: (1) framing the management question, (2) finding sources of information, (3) assessing the accuracy of the information, (4) assessing the applicability of the information, (5) assessing the actionability of the evidence, and (6) determining if the information is adequate. To build an organizational environment conducive to evidence-informed decision making, we suggest four leadership-driven strategies: (1) recognize and respond to the growing demand for accountability as a strategic issue, (2) establish organizational structures and processes for knowledge transfer, (3) build a questioning organizational culture, and (4) build organizational research capabilities. With organizational support, managers who use the tools presented in the Informed Decisions Toolbox will be able to take control of the decision-making process, will be less reliant on colloquial evidence and consultants, and will be better able to improve the performance of their organizations.

Objectives. To describe an implementation of one information technology system (electronic medical record, EMR) in one hospital, the perceived impact, the factors thought to help and hinder implementation and the success of the system and compare this with theories of effective IT implementation. To draw on previous research, empirical data from this study is used to develop IT implementation theory. Design. Qualitative case study, replicating the methods and questions of a previously published USA EMR implementation study using semi-structured interviews and documentation. Setting. Large Swedish teaching hospital shortly after a merger of two hospital sites. Participants. Thirty senior clinicians, managers, project team members, doctors and nurses. Results. The Swedish implementation was achieved within a year and for under half the budget, with a generally popular EMR which was thought to save time and improve the quality of patient care. Evidence from this study and findings from the more problematic USA implementation case suggests that key factors for cost effective implementation and operation were features of the system itself, the implementation process and the conditions under which the implementation was carried out. Conclusion. There is empirical support for the IT implementation theory developed in this study, which provides a sound basis for future research and successful implementation. Successful implementation of an EMR is likely with an intuitive system, requiring little training, already well developed for clinical work but allowing flexibility for development, where clinicians are involved in selection and in modification for their department needs and where a realistic timetable is made using an assessment of the change-capability of the organization. Once a system decision is made, the implementation should be driven by top and departmental leaders assisted by competent project teams involving information technology specialists and users. Corrections for unforeseen eventualities will be needed, especially with less developed systems, requiring regular reviews of progress and modifications to systems and timetables to respond to user needs.

This study examines the Chronic Care Model (CCM) as a framework for preventing health risk behaviors such as tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity. Data were obtained from primary care practices participating in a national health promotion initiative sponsored by the Robert Wood Johnson Foundation. Practices owned by a hospital health system and exhibiting a culture of quality improvement were more likely to offer recommended services such as health risk assessment, behavioral counseling, and referral to community-based programs. Practices that had a multispecialty physician staff and staff dieticians, decision support in the form of point-of-care reminders and clinical staff meetings, and clinical information systems such as electronic medical records were also more likely to offer recommended services. Adaptation of the CCM for preventive purposes may offer a useful framework for addressing important health risk behaviors.

PURPOSE It has been suggested that the best way to improve chronic illness care is through a redesign of primary care emphasizing comprehensive, coordinated care as espoused by the Chronic Care Model (CCM). This study examined the relationship between primary care orientation and the implementation of the CCM in physician organizations. METHODS The relationship between measures of primary care orientation and the CCM was examined in a sample of 957 physician organizations from the National Study of Physician Organizations, a cross-sectional telephone survey of all US medical groups and independent practice associations with 20 or more physicians (response rate, 70%). RESULTS After adjusting for potential confounders, 6 of 8 measures of primary care orientation were associated with physician organizations’ adoption of 11 elements of CCM chronic care management. These 6 measures were severity of chronic illness treated in primary care, health promotion activity, health education activity, any accepted financial risk for hospitalization, required reporting, and presence of an electronic standardized problem list. Presence of an electronic medical record and the 5-year primary care physician turnover rate were not associated. CONCLUSIONS Organizations that have adopted 6 core attributes of primary care, representing comprehensive health service delivery and a commitment to overall patient health, appear to use more chronic care management practices. Policy makers and other stakeholders may wish to focus on creating an improved primary care home in their quest to close the “quality chasm” in chronic illness care.