David N. Berg

Achieving Rapid Door-To-Balloon Times. How Top Hospitals Improve Complex Clinical Systems

Background— Fewer than half of patients with ST-elevation acute myocardial infarction (STEMI) are treated within guideline-recommended door-to-balloon times; however, little information is available about the approaches used by hospitals that have been successful in improving door-to-balloon times to meet guidelines. We sought to characterize experiences of hospitals with outstanding improvement in door-to-balloon time during 1999–2002. Methods and Results— We performed a qualitative study using in-depth interviews (n=122) with clinical and administrative staff at 11 hospitals that were participating with the National Registry of Myocardial Infarction and had median door-to-balloon times of ≤90 minutes during 2001–2002, representing substantial improvement since 1999. Data were organized with the use of NUD-IST 4 (Sage Publications Software) and were analyzed by the constant comparative method of qualitative data analysis. Eight themes characterized hospitals’ experiences: commitment to an explicit goal to improve door-to-balloon time motivated by internal and external pressures; senior management support; innovative protocols; flexibility in refining standardized protocols; uncompromising individual clinical leaders; collaborative teams; data feedback to monitor progress and identify problems and successes; and an organizational culture that fostered resilience to challenges or setbacks in improvement efforts. Conclusions— Several themes characterized the experiences of hospitals that had achieved notable improvements in their door-to-balloon times. By distilling the complex and diverse experiences of organizational change into its essential components, this study provides a foundation for future efforts to elevate clinical performance in the hospital setting.

What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates?: A Qualitative Study

BACKGROUND Mortality rates for patients with acute myocardial infarction (AMI) vary substantially across hospitals, even when adjusted for patient severity; however, little is known about hospital factors that may influence this variation. OBJECTIVE To identify factors that may be related to better performance in AMI care, as measured by risk-standardized mortality rates. DESIGN Qualitative study that used site visits and in-depth interviews. SETTING Eleven U.S. hospitals that ranked in either the top or the bottom 5% in risk-standardized mortality rates for 2 recent years of data from the Centers for Medicare & Medicaid Services (2005 to 2006 and 2006 to 2007), with diversity among hospitals in key characteristics. PARTICIPANTS 158 members of hospital staff, all of whom were involved with AMI care at the 11 hospitals. MEASUREMENTS Site visits and in-depth interviews conducted with hospital staff during 2009. A multidisciplinary team performed analyses by using the constant comparative method. RESULTS Hospitals in the high-performing and low-performing groups differed substantially in the domains of organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination among groups, and problem solving and learning. Participants described diverse protocols or processes for AMI care (such as rapid response teams, clinical guidelines, use of hospitalists, and medication reconciliation); however, these did not systematically differentiate high-performing from low-performing hospitals. LIMITATION The qualitative design informed the generation of hypotheses, and statistical associations could not be assessed. CONCLUSION High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality, United Health Foundation, and the Commonwealth Fund.

Exploring clinical methods for social research

Introduction - Kenwyn K Smith and David N Berg PART ONE: CLINICAL ISSUES The Clinical Demands of Research Methods - David N Berg and Kenwyn K Smith Taking Our Selves Seriously as Researchers - Clayton P Alderfer The Hermeneutic Turn and the Single Case Study in Psychoanalysis - Marshall Edelson Commentary PART TWO: CLINICAL UNDERSTANDING Action Usable Knowledge - Cortlandt Cammann Epistemological Problems in Researching Human Relationships - Kenwyn K Smith Looking at Research Ideas as Behavioral Data - Stewart E Perry Feminist Distrust - Shulamit Reinharz Problems of Context and Content in Sociological Work What Is Clinical Method? - Rodney L Lowman Commentary PART THREE: CLINICAL INVOLVEMENT On Seeking Ones Own Clinical Voice - J Richard Hackman A Personal Account Anxiety in Research Relationships - David N Berg Self-Full Research - Philip H Mirvis and Meryl Reis Louis Working Through the Self as Instrument in Organizational Research On the Researchers Group Memberships - Kathy E Kram Virtuous Subjectivity - Alan Peshkin In the Participant-Observers Is Commentary PART FOUR: CLINICAL METHODS Reconstructing an Organizations History - Valerie M Simmons Systematic Distortion in Retrospective Data History in the Here and Now - Jonathon H Gilette The Development of a Historical Perspective Using Participant-Observation to Construct a Life History - Helen Swick Perry On Studying Emotionally Hot Topics - Robert I Sutton and Susan J Schurman Lessons from an Investigation of Organizational Death Assessing Local Causality in Qualitative Research - A Michael Huberman and Matthew B Miles Commentary

Impact of race on the professional lives of physicians of African descent.

Diversifying the physician workforce is a national priority (1). However, despite efforts to increase the numbers of minority physicians (26), people of African descent represent only 2% to 3% of practicing physicians in the United States (7). Furthermore, this proportion has not changed substantially during the past 30 years (1, 8). Understanding how race influences the work experiences of physicians of African descent is fundamental to developing effective strategies to recruit and retain a diverse physician workforce. Evidence indicates that physicians of African descent face considerable challenges because of their race. Most minority physicians report that they have experienced racial or ethnic discrimination at work (912), and rates of reported racial discrimination are highest among physicians of African descent (10, 11). Studies of physicians in academic medicine show that medical school faculty of African descent have lower job satisfaction (11, 13) and are promoted less frequently (14, 15) than their nonminority counterparts who have similar productivity and similar academic accomplishments. Although this evidence documents the substantial prevalence of race-related challenges for physicians, qualitative information to understand how physicians of African descent experience race in the workplace is lacking. The design of interventions to successfully attract, integrate, and support a diverse workforce depends on a clear understanding of the role of race in the professional lives of physicians. Therefore, we sought to characterize these experiences through in-depth interviews with physicians of African descent practicing in academic and nonacademic settings and across a range of clinical specialties. We used qualitative data analysis techniques to identify the unifying and recurrent themes that show how race shapes the work experiences of physicians of African descent. Methods Study Design and Sample We conducted a qualitative study by using in-depth interviews with 25 physicians who identified themselves as being of African descent and who practiced in 1 of the 6 New England states. People of African descent include Africans and African Americans and those from other regions of the African diaspora, such as African Caribbeans. We did not interview physicians of other races because we only studied how physicians of African descent experience race at work. We chose a qualitative approach to explore a complex and potentially sensitive topic involving social and cultural interactions that are difficult to measure quantitatively (16, 17). On the basis of principles of grounded qualitative research, we aimed to generate hypotheses from the data as opposed to testing prespecified hypotheses (1620). We recruited an information-rich and purposeful sample (16, 17) of physicians of African descent from the 6 New England states. We excluded physicians in training. We identified potential participants from the membership roster of the New England Medical Society (an organization of minority physicians); the Web-based African American physician locator, which uses membership data from the National Medical Association; community-based organizations; and regional academic institutions. We randomly selected physicians from among those who responded to an invitation to participate within the first 2 weeks. In addition, using the snowball technique (16, 17), we asked study participants to provide names of other physicians of African descent in the region. All invited physicians agreed to participate. We interviewed practicing physicians until no new themes emerged from successive interviews, that is, until thematic saturation was achieved. The research protocol was approved by the Human Investigation Committee of the Yale University School of Medicine, New Haven, Connecticut. We obtained verbal informed consent from participants. Data Collection One of the researchers conducted in-person, in-depth interviews (21). Interviews were racially concordant and consisted of the interviewer and an individual participant. The average length of the recorded interview was 40 minutes. Professional transcriptionists transcribed interviews, and the interviewer reviewed the transcriptions to ensure accuracy. Interviews (Figure) began with a broad question: How do you think race influences your experiences at work? Specific questions addressed negative and positive work experiences attributed to race and the influence of race on the physicians career trajectories. Probes were used to encourage participants to clarify and elaborate on their statements as necessary. Figure. Standard interview guide. Statistical Analysis In the first stage of analysis, codes were created and defined as concepts that emerged from the data in an inductive fashion (21, 22). The coding team independently coded transcripts line by line and, as needed, met as a group to reach consensus. Using the constant comparative method of qualitative analysis (21, 22), we compared coded text to identify novel themes and expand existing themes, refining the codes as appropriate until we reached a final coding structure that comprehensively defined all codes (22, 23). Using this final coding structure, the researchers independently coded 3 previously uncoded transcripts. The calculated intercoder agreement was 80%, which is considered acceptable by qualitative research standards (24). One researcher then used the final code structure to recode all transcripts. We used qualitative analysis software (ATLAS.ti 5.0, Scientific Software Development, Berlin, Germany) to facilitate data organization and retrieval (25). As recommended by experts in qualitative analysis (23), participants reviewed a summary of the data and endorsed the content of the themes after the analysis was complete. Role of the Funding Sources The funding sources had no role in the design, analysis, or reporting of the study or in the design to submit the manuscript for publication. Results Physician participants represented a range of practice settings, specialties, and ages (Table). Five recurrent themes characterized how physicians of African descent experienced race in the health care workplace: 1) awareness of race permeates the experience of physicians of African descent in the health care workplace; 2) race-related experiences shape interpersonal interactions and define the institutional climate; 3) responses to perceived racism at work vary along a spectrum from minimization to confrontation; 4) the health care workplace is often silent on issues of race; and 5) these experiences can result in what we term racial fatigue, with personal and professional consequences for physicians. We provide verbatim quotations to illustrate each theme. Table. Characteristics of the 25 Study Participants* Awareness of Race Permeates the Experience of Physicians of African Descent in the Health Care Workplace All participants described race as pervading their identity and experiences in the health care workplace. Physicians offered several examples of how race often influenced their professional experiences. A general surgeon at an academic institution commented on his perception of how he is viewed by others at work: I think race permeates every aspect of my job; so when I walk onto a ward or on the floor, Im a black guy before Im the doctor. Im still a black guy before Im the guy in charge, before Im the attending of record, so that permeates everything. Participants also described the importance of race in influencing their self-view in the workplace. For some physicians, the influence of race on self-view was shaped by the participants country of origin. A general internist at an academic institution who is from the United States reflected: I am your classic African American. What I mean by that is that I think about race all the time. At least 50 times a day. I wouldnt say race has influenced me. It defines me. It defines what I do. [It defines] everything. In contrast, a physician practicing family medicine at an academic institution who immigrated to the United States as an undergraduate student stated: Race influences the personalities of Americans much more deeply than for Africans or other people not born in this country. As an African, my primary mode of identification is not race. Still, most people [in this country] see me and for them its race. [S]o it definitely affects what I do. Its probably the most important thing. Regardless of where they were from, participants reported constant awareness of their racial minority status in the workplace. However, physicians sometimes tried to take the focus off of race in the workplace. An internal medicine subspecialist working at a hospital-based practice reflected: Growing up as I did in this country, however, I am perpetually aware of race with every individual that I meet, my cofaculty, my patients, the other health care workers here, but I think I have tried to take an approach that to whatever extent possible, I try to take race out of the equation. Regardless of whether participants focused on the influence of race at work, they reflected on the intersection of authority and race in their work lives. A pediatrician at an academic institution said the following: It is hard being a physician of color because you have the issue of race and the issue of power. When you are a physician, you have a power position that other people dont have, whether they are of the same race or different race or whatever. So, sometimes it is tricky. Are you annoyed that I am in the position that I am in or [are you] annoyed about my position because of my race? Race-Related Experiences Shape Interpersonal Interactions and Define the Institutional Climate Race influenced the professional lives of all participants. They described the effect of race on their relationships with patients, staff, and colleagues and its effect on their roles in the broader health care institutional envi

The Role of Group Dynamics in Mixed Methods Health Sciences Research Teams

This article explores the group dynamics of mixed methods health sciences research teams. The authors conceptualize mixed methods research teams as “representational groups,” in which members bring both their organizational and professional groups (e.g., organizational affiliations, methodological expertise) and their identity groups, such as gender or race, to the work of research. Although diversity and complementarity are intrinsic to mixed methods teams, these qualities also present particular challenges. Such challenges include (a) dealing with differences, (b) trusting the “other,” (c) creating a meaningful group, (d) handling essential conflicts and tensions, and (e) enacting effective leadership roles. The authors describe these challenges and, drawing from intergroup relations theory, propose guiding principles that may be useful to mixed methods health sciences research teams.

Professional experiences of international medical graduates practicing primary care in the United States.

BackgroundInternational medical graduates (IMGs) comprise approximately 25% of the US physician workforce, with significant representation in primary care and care of vulnerable populations. Despite the central role of IMGs in the US healthcare system, understanding of their professional experiences is limited.ObjectiveTo characterize the professional experiences of non-US born IMGs from limited-resource nations practicing primary care in the US.DesignQualitative study based on in-depth in-person interviews.ParticipantsPurposeful sample of IMGs (n = 25) diverse in country of origin, length of practice in the US, specialty (internal medicine, family medicine and pediatrics), age and gender. Participants were currently practicing primary care physicians in New York, New Jersey or Connecticut.ApproachA standardized interview guide was used to explore professional experiences of IMGs.Key ResultsFour recurrent and unifying themes characterize these experiences: 1) IMGs experience both overt and subtle forms of workplace bias and discrimination; 2) IMGs recognize professional limitations as part of “the deal”; 3) IMGs describe challenges in the transition to the culture and practice of medicine in the US; 4) IMGs bring unique skills and advantages to the workplace.ConclusionsOur data reveal that IMGs face workplace challenges throughout their careers. Despite diversity in professional background and demographic characteristics, IMGs in our study reported common experiences in the transition to and practice of medicine in the US. Findings suggest that both workforce and workplace interventions are needed to enable IMG physicians to sustain their essential and growing role in the US healthcare system. Finally, commonalities with experiences of other minority groups within the US healthcare system suggest that optimizing IMGs’ experiences may also improve the experiences of an increasingly diverse healthcare workforce.

A model for scale up of family health innovations in low-income and middle-income settings: a mixed methods study.

Background Many family health innovations that have been shown to be both efficacious and cost-effective fail to scale up for widespread use particularly in low-income and middle-income countries (LMIC). Although individual cases of successful scale-up, in which widespread take up occurs, have been described, we lack an integrated and practical model of scale-up that may be applicable to a wide range of public health innovations in LMIC. Objective To develop an integrated and practical model of scale-up that synthesises experiences of family health programmes in LMICs. Data sources We conducted a mixed methods study that included in-depth interviews with 33 key informants and a systematic review of peer-reviewed and grey literature from 11 electronic databases and 20 global health agency web sites. Study eligibility criteria, participants and interventions We included key informants and studies that reported on the scale up of several family health innovations including Depo-Provera as an example of a product innovation, exclusive breastfeeding as an example of a health behaviour innovation, community health workers (CHWs) as an example of an organisational innovation and social marketing as an example of a business model innovation. Key informants were drawn from non-governmental, government and international organisations using snowball sampling. An article was excluded if the article: did not meet the studys definition of the innovation; did not address dissemination, diffusion, scale up or sustainability of the innovation; did not address low-income or middle-income countries; was superficial in its discussion and/or did not provide empirical evidence about scale-up of the innovation; was not available online in full text; or was not available in English, French, Spanish or Portuguese, resulting in a final sample of 41 peer-reviewed articles and 30 grey literature sources. Study appraisal and synthesis methods We used the constant comparative method of qualitative data analysis to extract recurrent themes from the interviews, and we integrated these themes with findings from the literature review to generate the proposed model of scale-up. For the systematic review, screening was conducted independently by two team members to ensure consistent application of the predetermined exclusion criteria. Data extraction from the final sample of peer-reviewed and grey literature was conducted independently by two team members using a pre-established data extraction form to list the enabling factors and barriers to dissemination, diffusion, scale up and sustainability. Results The resulting model—the AIDED model—includes five non-linear, interrelated components: (1) assess the landscape, (2) innovate to fit user receptivity, (3) develop support, (4) engage user groups and (5) devolve efforts for spreading innovation. Our findings suggest that successful scale-up occurs within a complex adaptive system, characterised by interdependent parts, multiple feedback loops and several potential paths to achieve intended outcomes. Failure to scale up may be attributable to insufficient assessment of user groups in context, lack of fit of the innovation with user receptivity, inability to address resistance from stakeholders and inadequate engagement with user groups. Limitations The inductive approach used to construct the AIDED model did not allow for simultaneous empirical testing of the model. Furthermore, the literature may have publication bias in which negative studies are under-represented, although we did find examples of unsuccessful scale-up. Last, the AIDED model did not address long-term, sustained use of innovations that are successfully scaled up, which would require longer-term follow-up than is common in the literature. Conclusions and implications of key findings Flexible strategies of assessment, innovation, development, engagement and devolution are required to enable effective change in the use of family health innovations in LMIC.

Attrition from surgical residency training: perspectives from those who left.

BACKGROUND High rates of attrition from general surgery residency may threaten the surgical workforce. We sought to gain further insight regarding resident motivations for leaving general surgery residency. METHODS We conducted in-depth interviews to generate rich narrative data that explored individual experiences. An interdisciplinary team used the constant comparative method to analyze the data. RESULTS Four themes characterized experiences of our 19 interviewees who left their residency program. Participants (1) felt an informal contract was breached when clinical duties were prioritized over education, (2) characterized a culture in which there was no safe space to share personal and programmatic concerns, (3) expressed a scarcity of role models who demonstrated better work-life balance, and (4) reported negative interactions with authority resulting in a profound loss of commitment. CONCLUSIONS As general surgery graduate education continues to evolve, our findings may inform interventions and policies regarding programmatic changes to boost retention in surgical residency.

Healthcare Workplace Conversations on Race and the Perspectives of Physicians of African Descent

BackgroundAlthough experts recommend that healthcare organizations create forums for honest dialogue about race, there is little insight into the physician perspectives that may influence these conversations across the healthcare workforce.ObjectiveTo identify the range of perspectives that might contribute to workplace silence on race and affect participation in race-related conversations within healthcare settings.DesignIn-person, in-depth, racially concordant qualitative interviews.ParticipantsTwenty-five physicians of African descent practicing in the 6 New England states.ApproachLine-by-line independent coding and group negotiated consensus to develop codes structure using constant comparative method.Main ResultsFive themes characterize perspectives of participating physicians of African descent that potentially influence race-related conversations at work: 1) Perceived race-related healthcare experiences shape how participating physicians view healthcare organizations and their professional identities prior to any formal medical training; 2) Protecting racial/ethnic minority patients from healthcare discrimination is a top priority for participating physicians; 3) Participating physicians often rely on external support systems for race-related issues, rather than support systems inside the organization; 4) Participating physicians perceive differences between their interpretations of potentially offensive race-related work experiences and their non-minority colleagues’ interpretations of the same experiences; and 5) Participating physicians are uncomfortable voicing race-related concerns at work.ConclusionsCreating a healthcare work environment that successfully supports diversity is as important as recruiting diversity across the workforce. Developing constructive ways to discuss race and race relations among colleagues in the workplace is a key step towards creating a supportive environment for employees and patients from all backgrounds.

Senior executive teams: Not what you think.

This article examines the special characteristics of representational groups, especially as they apply to senior executive teams. Senior executives are expected to function as both representatives of their divisions or functions and as corporate officers charged with organizationwide planning and decision making. This situation brings with it certain inherent tensions. A description of these tensions is followed by a discussion of the characteristics of representational dynamics. The article concludes with suggestions for how these tensions and dynamics can be managed more effectively on senior executive teams.