Michael I. Harrison

Redesigning Health Systems for Quality: Lessons from Emerging Practices

BACKGROUND It has been five years since the Institute of Medicine (IOM) report, Crossing the Quality Chasm, proposed systemwide changes to transform our health care system. What progress has been made? What lessons have been learned? How should we move forward? METHODS Semistructured telephone interviews were conducted with 16 health care providers and researchers at organizations involved in system redesign. The findings were supplemented with a focused literature review and discussions from a national expert meeting. RESULTS Many promising and innovative examples of redesign were identified. However, even delivery systems that are redesigning care in pursuit of the six IOM aims face daunting challenges, reflecting the need to align system changes across multiple levels and to integrate redesign efforts with ongoing system features. Four success factors were reported by providers as crucial in overcoming redesign barriers: (1) directly involving top and middle-level leaders, (2) strategically aligning and integrating improvement efforts with organizational priorities, (3) systematically establishing infrastructure, process, and performance appraisal systems for continuous improvement, and (4) actively developing champions, teams, and staff. A framework that integrates these success factors to facilitate a systems approach to redesigning health care organizations and delivery systems for improved performance is provided. CONCLUSIONS Successful system redesign requires coordinating and managing a complex set of changes across multiple levels rather than isolated projects.

High-performance work systems in health care management, Part 1: Development of an evidence-informed model

Background: Although management practices are recognized as important factors in improving health care quality and efficiency, most research thus far has focused on individual practices, ignoring or underspecifying the contexts within which these practices are operating. Research from other industries, which has increasingly focused on systems rather than individual practices, has yielded results that may benefit health services management. Purpose: Our goal was to develop a conceptual model on the basis of prior research from health care as well as other industries that could be used to inform important contextual considerations within health care. Methodology/Approach: Using theoretical frameworks from A. Donabedian (1966), P. M. Wright, T. M. Gardner, and L. M. Moynihan (2003), and B. Schneider, D. B. Smith, and H. W. Goldstein (2000) and review methods adapted from R. Pawson (2006b), we reviewed relevant research from peer-reviewed and other industry-relevant sources to inform our model. The model we developed was then reviewed with a panel of practitioners, including experts in quality and human resource management, to assess the applicability of the model to health care settings. Findings: The resulting conceptual model identified four practice bundles, comprising 14 management practices as well as nine factors influencing adoption and perceived sustainability of these practices. The mechanisms by which these practices influence care outcomes are illustrated using the example of hospital-acquired infections. In addition, limitations of the current evidence base are discussed, and an agenda for future research in health care settings is outlined. Practice Implications: Results may help practitioners better conceptualize management practices as part of a broader system of work practices. This may, in turn, help practitioners to prioritize management improvement efforts more systematically.BACKGROUND : A capable workforce is central to the delivery of high-quality care. Research from other industries suggests that the methodical use of evidence-based management practices (also known as high-performance work practices [HPWPs]), such as systematic personnel selection and incentive compensation, serves to attract and retain well-qualified health care staff and that HPWPs may represent an important and underutilized strategy for improving quality of care and patient safety. PURPOSE : The aims of this study were to improve our understanding about the use of HPWPs in health care organizations and to learn about their contribution to quality of care and patient safety improvements. METHODOLOGY/APPROACH : Guided by a model of HPWPs developed through an extensive literature review and synthesis, we conducted a series of interviews with key informants from five U.S. health care organizations that had been identified based on their exemplary use of HPWPs. We sought to explore the applicability of our model and learn whether and how HPWPs were related to quality and safety. All interviews were recorded, transcribed, and subjected to qualitative analysis. FINDINGS : In each of the five organizations, we found emphasis on all four HPWP subsystems in our conceptual model-engagement, staff acquisition/development, frontline empowerment, and leadership alignment/development. Although some HPWPs were common, there were also practices that were distinctive to a single organization. Our informants reported links between HPWPs and employee outcomes (e.g., turnover and higher satisfaction/engagement) and indicated that HPWPs made important contributions to system- and organization-level outcomes (e.g., improved recruitment, improved ability to address safety concerns, and lower turnover). PRACTICE IMPLICATIONS : These case studies suggest that the systematic use of HPWPs may improve performance in health care organizations and provide examples of how HPWPs can impact quality and safety in health care. Further research is needed to specify which HPWPs and systems are of greatest potential for health care management.

High-performance work systems in health care management, part 2: qualitative evidence from five case studies.

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

Organizational Transformation: A Systematic Review of Empirical Research in Health Care and Other Industries

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

Negotiating time scripts during implementation of an electronic medical record.

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

Improving the Health Care Work Environment: A Sociotechnical Systems Approach

This issue examines findings on key elements of the hospital environment, identifies risks to safety and quality, and proposes operational and policy solutions.

Effects of organizational context on Lean implementation in five hospital systems.

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

Integrating mixed methods in health services and delivery system research.

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

Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review

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

Implementation of Care Management: An Analysis of Recent AHRQ Research.

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