Martin P. Charns

Transformational change in health care systems: an organizational model.

Background: The Institute of Medicines 2001 report Crossing the Quality Chasm argued for fundamental redesign of the U.S. health care system. Six years later, many health care organizations have embraced the reports goals, but few have succeeded in making the substantial transformations needed to achieve those aims. Purposes: This article offers a model for moving organizations from short-term, isolated performance improvements to sustained, reliable, organization-wide, and evidence-based improvements in patient care. Methodology: Longitudinal comparative case studies were conducted in 12 health care systems using a mixed-methods evaluation design based on semistructured interviews and document review. Participating health care systems included seven systems funded through the Robert Wood Johnson Foundations Pursuing Perfection Program and five systems with long-standing commitments to improvement and high-quality care. Findings: Five interactive elements appear critical to successful transformation of patient care: (1) Impetus to transform; (2) Leadership commitment to quality; (3) Improvement initiatives that actively engage staff in meaningful problem solving; (4) Alignment to achieve consistency of organization goals with resource allocation and actions at all levels of the organization; and (5) Integration to bridge traditional intra-organizational boundaries among individual components. These elements drive change by affecting the components of the complex health care organization in which they operate: (1) Mission, vision, and strategies that set its direction and priorities; (2) Culture that reflects its informal values and norms; (3) Operational functions and processes that embody the work done in patient care; and (4) Infrastructure such as information technology and human resources that support the delivery of patient care. Transformation occurs over time with iterative changes being sustained and spread across the organization. Practice Implications: The conceptual model holds promise for guiding health care organizations in their efforts to pursue the Institute of Medicine aims of fundamental system redesign to achieve dramatically improved patient care.

Validating risk-adjusted surgical outcomes: site visit assessment of process and structure1

Abstract Background: Risk-adjusted mortality and morbidity rates are often used as measures of the quality of surgical care. This study was conducted to determine the validity of risk-adjusted surgical morbidity and mortality rates as measures of quality of care by assessing the process and structure of care in surgical services with higher-than-expected and lower-than-expected risk-adjusted 30-day mortality and morbidity rates. Study Design: A structural survey of 44 Veterans Affairs Medical Center surgical services and site visits to 20 surgical services with higher-than-expected and lower-than-expected risk-adjusted outcomes were conducted. Main outcome measures included assessment of technology and equipment, technical competence of staff, leadership, relationship with other services, monitoring of quality of care, coordination of work, relationship with affiliated institutions, and overall quality of care. Results: Surgical services with lower-than-expected risk-adjusted surgical morbidity and mortality rates had significantly more equipment available in surgical intensive care units than did services with higher-than-expected outcomes (4.3 versus 2.9, p Conclusions: Significant differences in several dimensions of process and structure of the delivery of surgical care are associated with differences in risk-adjusted surgical morbidity and mortality rates among 44 Veterans Affairs Medical Centers.

Best Practices for Managing Surgical Services: The Role of Coordination

Growing evidence exists that patient outcomes are related to how effectively health care organizations coordinate work responsibilities among their staffs. However, information is lacking on actual practices that can be used to achieve effective coordination. This article reports on a National Veterans Affairs Surgical Risk Study, in which the authors studied the coordination practices of 20 surgical services that, based on risk-adjusted mortality and morbidity rates, occupied different ends of the patient outcomes continuum.

Improving Quality of Care through Routine, Successful Implementation of Evidence-Based Practice at the Bedside: An Organizational Case Study Protocol Using the Pettigrew and Whipp Model of Strategic Change

BackgroundEvidence-based practice (EBP) is an expected approach to improving the quality of patient care and service delivery in health care systems internationally that is yet to be realized. Given the current evidence-practice gap, numerous authors describe barriers to achieving EBP. One recurrently identified barrier is the setting or context of practice, which is likewise cited as a potential part of the solution to the gap. The purpose of this study is to identify key contextual elements and related strategic processes in organizations that find and use evidence at multiple levels, in an ongoing, integrated fashion, in contrast to those that do not.MethodsThe core theoretical framework for this multi-method explanatory case study is Pettigrew and Whipps Content, Context, and Process model of strategic change. This framework focuses data collection on three entities: the Why of strategic change, the What of strategic change, and the How of strategic change, in this case related to implementation and normalization of EBP. The data collection plan, designed to capture relevant organizational context and related outcomes, focuses on eight interrelated factors said to characterize a receptive context. Selective, purposive sampling will provide contrasting results between two cases (departments of nursing) and three embedded units in each. Data collection methods will include quantitative tools (e.g., regarding culture) and qualitative approaches including focus groups, interviews, and documents review (e.g., regarding integration and “success”) relevant to the EBP initiative.DiscussionThis study should provide information regarding contextual elements and related strategic processes key to successful implementation and sustainability of EBP, specifically in terms of a pervasive pattern in an acute care hospital-based health care setting. Additionally, this study will identify key contextual elements that differentiate successful implementation and sustainability of EBP efforts, both within varying levels of a hospital-based clinical setting and across similar hospital settings interested in EBP.

Implementing Quality Improvement in Hospitals: The Role of Leadership and Culture

Many advocates of quality improvement (QI) suggest that there is a link between an organizations leadership commitment and culture and its ability to implement a QI initiative. This paper reports empirical evidence from a study of QI implementation in Veterans Health Administration (VHA) hospitals that supports this hypothesized linkage. The findings suggest that the extent to which top management becomes directly involved in QI activities determines the degree of QI implementation. Additionally, study findings suggest that a culture emphasizing innovation and teamwork provides an important foundation for implementing a QI initiative. We discuss the implications of these findings for organizational leaders interested in implementing QI.

Leadership for Evidence‐Based Practice: Strategic and Functional Behaviors for Institutionalizing EBP

Background Making evidence-based practice (EBP) a reality throughout an organization is a challenging goal in healthcare services. Leadership has been recognized as a critical element in that process. However, little is known about the exact role and function of various levels of leadership in the successful institutionalization of EBP within an organization. Aims To uncover what leaders at different levels and in different roles actually do, and what actions they take to develop, enhance, and sustain EBP as the norm. Methods Qualitative data from a case study regarding institutionalization of EBP in two contrasting cases (Role Model and Beginner hospitals) were systematically analyzed. Data were obtained from multiple interviews of leaders, both formal and informal, and from staff nurse focus groups. A deductive coding schema, based on concepts of functional leadership, was developed for this in-depth analysis. Results Participants’ descriptions reflected a hierarchical array of strategic, functional, and cross-cutting behaviors. Within these macrolevel “themes,” 10 behavioral midlevel themes were identified; for example, Intervening and Role modeling. Each theme is distinctive, yet various themes and their subthemes were interrelated and synergistic. These behaviors and their interrelationships were conceptualized in the framework “Leadership Behaviors Supportive of EBP Institutionalization” (L-EBP). Leaders at multiple levels in the Role Model case, both formal and informal, engaged in most of these behaviors. Linking Evidence to Action Supportive leadership behaviors required for organizational institutionalization of EBP reflect a complex set of interactive, multifaceted EBP-focused actions carried out by leaders from the chief nursing officer to staff nurses. A related framework such as L-EBP may provide concrete guidance needed to underpin the often-noted but abstract finding that leaders should “support” EBP.

Quality of general medical care among patients with serious mental illness: Does colocation of services matter?

OBJECTIVE This study was conducted to determine whether patients with serious mental illness receiving care in Veterans Affairs (VA) mental health programs with colocated general medical clinics were more likely to receive adequate medical care than patients in programs without colocated clinics based on a nationally representative sample. METHODS The study included all VA patients with diagnoses of serious mental illness in fiscal year (FY) 2006-2007 who were also part of the VAs External Peer Review Program (EPRP) FY 2007 random sample and who received care from VA facilities (N=107 facilities) with organizational data from the VA Mental Health Program Survey (N=7,514). EPRP included patient-level chart review quality indicators for common processes of care (foot and retinal examinations for diabetes complications; screens for colorectal health, breast cancer, and alcohol misuse; and tobacco counseling) and outcomes (hypertension, diabetes blood sugar, and lipid control). RESULTS Ten out of 107 (10%) mental health programs had colocated medical clinics. After adjustment for organizational and patient-level factors, analyses showed that patients from colocated clinics compared with those without colocation were more likely to receive foot exams (OR=1.87, p<.05), colorectal cancer screenings (OR=1.54, p<.01), and alcohol misuse screenings (OR=2.92, p<.01). They were also more likely to have good blood pressure control (<140/90 mmHg; OR=1.32, p<.05) but less likely to have glycosylated hemoglobin <9% (OR=.69, p<.05). CONCLUSIONS Colocation of medical care was associated with better quality of care for four of nine indicators. Additional strategies, particularly those focused on improving diabetes control and other chronic medical outcomes, might be warranted for patients with serious mental illness.

Clinical service lines in integrated delivery systems: an initial framework and exploration.

EXECUTIVE SUMMARY The increasing pressures on integrated healthcare delivery systems (IDSs) to provide coordinated and cost‐effective care focuses attention on the question of how to best integrate across multiple sites of care. One increasingly common approach to this issue is the development of clinical service lines that integrate specific bundles of services across the operating units of a system. This article presents a conceptual model of service lines and reports results from a descriptive investigation of service line development among members of the Industry Advisory Board—a research consortium comprising IDSs. The experiences of these IDSs (1) provide valuable insights into the range of organizational arrangements and implementation issues that are associated with service line management in healthcare systems and (2) suggest aspects of service line management worthy of further inquiry.

Screening for mild traumatic brain injury in OEF-OIF deployed US military: An empirical assessment of VHA's experience

Background: VHA screens for traumatic brain injury (TBI) among patients formerly deployed to Afghanistan or Iraq, referring those who screen positive for a Comprehensive TBI Evaluation (CTBIE). Methods: To assess the programme, rates were calculated of positive screens for potential TBI in the population of patients screened in VHA between October 2007 through March 2009. Rates were derived of TBI confirmed by comprehensive evaluations from October 2008 through July 2009. Patient characteristics were obtained from Department of Defense and VHA administrative data. Results: In the study population, 21.6% screened positive for potential TBI and 54.6% of these had electronic records of a CTBIE. Of those with CTBIE records, evaluators confirmed TBI in 57.7%, yielding a best estimate that 6.8% of all those screened were confirmed to have TBI. Three quarters of all screened patients and virtually all those evaluated (whether TBI was confirmed or not) had VHA care the following year. Conclusions: VHAs TBI screening process is inclusive and has utility in referring patients with current symptoms to appropriate care. More than 90% of those evaluated received further VHA care and confirmatory evaluations were associated with significantly higher average utilization. Generalizability is limited to those who seek VHA healthcare.

The effects of organization on medical utilization: an analysis of service line organization.

ObjectivesTo determine whether clinical service lines in primary care and mental health reduces inpatient and urgent care utilization. MethodsAll VHA medical centers were surveyed to determine whether service lines had been established in primary care or mental health care prior to the beginning of fiscal year 1997 (FY97). Facility-level data on medical utilization from Veterans Health Affairs (VHA) administrative databases were used for descriptive and multivariate regression analyses of utilization and of changes in measures between FY97 and FY98. Nine primary care–related and 5 mental health–related variables were analyzed. Principal FindingsPrimary care and mental health service lines had been established in approximately half of all facilities. Service lines varied in duration and extent of restructuring. Mere presence of a service line had no positive and several negative effects on measured outcome variables. More detailed analyses showed that some types of service lines have statistically significant and mostly negative effects on both mental health and primary care–related measures. Newly implemented service lines had significantly less improvement in measures over time than facilities with no service line. ConclusionsHealth care organizations are implementing innovative organizational structures in hopes of improving quality of care and reducing resource utilization. We found that service lines in primary care and mental health may lead to an initial period of disruption, with little evidence of a beneficial effect on performance for longer duration service lines.