Paula H. Song

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.

The Role of Cognitive and Learning Theories in Supporting Successful EHR System Implementation Training: A Qualitative Study

Given persistent barriers to effective electronic health record (EHR) system implementation and use, the authors investigated implementation training practices in six organizations reputed to have ambulatory care EHR system implementation “best practices.” Using the lenses of social cognitive and adult learning theories, they explored themes related to EHR implementation training using qualitative data collected through 43 key informant interviews and 6 physician focus groups conducted between February 2009 and December 2010. The authors found consistent evidence that training practices across the six organizations known for exemplary implementations were congruent with the tenets of these theoretical frameworks and highlight seven best practices for training. The authors’ analyses suggest that effective training programs must move beyond technical approaches and incorporate social and cultural factors to make a difference in implementation success. Taking these findings into account may increase the likelihood of successful EHR implementation, thereby helping organizations meet “meaningful use” requirements for EHR systems.

Minding the Gap A Decomposition of Emergency Department Use by Medicaid Enrollees and the Uninsured

Objective:To examine differences in Emergency Department (ED) utilization between Medicaid enrollees and the uninsured. Data and Methods:We use nationally representative data for adults age 19–64 from the 2004 Medical Expenditure Panel Survey. We calculate descriptive statistics highlighting differences in distributions of measurable characteristics and logit regressions describing differences in the coefficients of the characteristics between the 2 groups. Blinder-Oaxaca nonlinear decomposition methods are applied to quantify the effect that differences in measurable characteristics between the groups have on the differences in ED utilization, as well as examine the magnitude of the effect on utilization of differences in behavior between the groups. Results:Twenty-seven percent of Medicaid enrollees had an ED visit, whereas 10% of those uninsured the entire year had an ED visit. Roughly half of the utilization gap can be explained by differences in measurable characteristics. Although predisposing factors such as demographic and socioeconomic characteristics explain little of the gap, the variables capturing health limitations reflecting need explain a more substantial amount of the gap. Specifically, the higher presence of chronic conditions reported by Medicaid enrollees accounts for 18 percentage points of the gap, and reporting fair or poor health status explains 10 percentage points of the disparity. Conclusions:Decomposition analysis results show that differences in measurable characteristics between the groups explain half of the disparity in visits. The remaining portion of the gap in ED utilization is driven by differences in unmeasured or unobserved characteristics between the groups such as care-seeking behavioral differences.

Moving from Good to Great in Ambulatory Electronic Health Record Implementation

&NA; Despite a good general understanding of the need to ensure provider adoption and use of electronic health record (EHR) systems, many implementations fall short of expectations, and little is known about effective approaches in the ambulatory care area. We aimed to comprehensively study and synthesize best practices for ambulatory EHR system implementation in healthcare organizations, emphasizing strategies that maximize physician adoption and use. Following an extensive literature review, we held 47 key informant interviews with representatives of six U.S. healthcare organizations purposively selected based on reported success with ambulatory EHR system implementation. We interviewed both administrative and clinical informants in order to improve our understanding of ambulatory EHR implementation from both perspectives. We found that while all 6 sites studied were reported to have strong EHR implementation practices, we were able to characterize “good” versus “great” approaches across the sites. Specifically, “great” implementations included a key element focused on optimization and improvement over time that helped healthcare organizations support physician adoption and use of the EHR system. The “great” implementation approaches we saw also included explicit considerations of improved data capture and quality of care in their focus on optimization in order to maximize the value of the EHR.

High-performance work systems in health care, part 3: the role of the business case.

Background: Growing evidence suggests the systematic use of high-performance work practices (HPWPs), or evidence-based management practices, holds promise to improve organizational performance, including improved quality and efficiency, in health care organizations. However, little is understood about the investment required for HPWP implementation, nor the business case for HPWP investment. Purpose: The aim of this study is to enhance our understanding about organizations’ perspectives of the business case for HPWP investment, including reasons for and approaches to evaluating that investment. Methodology/Approach: We used a multicase study approach to explore the business case for HPWPs in U.S. health care organizations. We conducted semistructured interviews with 67 key informants across five sites. All interviews were recorded, transcribed, and subjected to qualitative analysis using both deductive and inductive methods. Findings: The organizations in our study did not appear to have explicit financial return expectations for investments in HPWPs. Instead, the HPWP investment was viewed as an important factor contributing to successful execution of the organization’s strategic priorities and a means for competitive differentiation in the market. Informants’ characterizations of the HPWP investment did not involve financial terms; rather, descriptions of these investments as redeployment of existing resources or a shift of managerial time redirected attention from cost considerations. Evaluation efforts were rare, with organizations using broad organizational metrics to justify HPWP investment or avoiding formal evaluation altogether. Practice Implications: Our findings are consistent with prior studies that have found that health care organizations have not systematically evaluated the financial outcomes of their quality-related initiatives or tend to forgo formal business case analysis for investments they may perceive as “inevitable.” In the absence of a clearly described association between HPWPs and outcomes or some other external imperative, ongoing HPWP investment may be at risk relative to other quality-related initiatives, particularly if organizational resources are constrained.

Nonoperating revenue and hospital financial performance: Do hospitals rely on income from nonpatient care activities to offset losses on patient care?

BACKGROUND For many years, hospitals have relied on nonpatient care activities to complement patient care revenues and strengthen financial performance. For hospitals that lose money on patient care, nonpatient care revenues may mean the difference between net income and loss. Little is known currently, however, about whether nonpatient care revenues allow hospitals with negative patient care margins to offset their losses. PURPOSE The aims of this study are (a) to examine whether hospitals rely on income from nonpatient care activities to offset losses on patient care and (b) to identify characteristics of hospitals that are able to offset such losses. DATA AND METHODS Data for this study came from the state of California. The sample consisted of not-for-profit and investor-owned short-term general acute care hospitals for the years 2003-2007. Descriptive statistics were used to compare hospitals with negative patient care margins that were able to offset patient care losses to hospitals that were unable to do so. FINDINGS Between 2003 and 2007, approximately 40% of study hospitals lost money on patient care. Of these, only 25% relied on nonpatient care income to offset losses. Hospitals that were able to offset patient care losses tended to be larger, not-for-profit organizations that were able to generate substantial shares of their total revenues from nonpatient care activities, in particular, charitable donations and financial investments. PRACTICE IMPLICATIONS Despite claims that income from nonpatient care activities frequently allows hospitals to offset patient care losses, this study showed that only a small proportion of hospitals were able to do so. The financial viability of hospitals with negative patient care margins will thus depend on their ability to (a) deliver high-quality care profitably, (b) derive income from other operating activities, and (c) generate income from financial investments and engage in active development efforts to increase donations and gifts.

Trends in asset structure between not-for-profit and investor-owned hospitals.

The delivery of health care is a capital-intensive industry, and thus, hospital investment strategy continues to be an important area of interest for both health policy and research. Much attention has been given to hospitals’ capital investment policies with relatively little attention to investments in financial assets, which serve an important role in not-for-profit (NFP) hospitals. This study describes and analyzes trends in aggregate asset structure between NFP and investor-owned (IO) hospitals during the post-capital-based prospective payment system implementation period, providing the first documentation of long-term trends in hospital investment. The authors find hospitals’ aggregate asset structure differs significantly based on ownership, size, and profitability. For both NFP and IO hospitals, financial securities have remained consistent over time, while fixed asset representation has declined in IO hospitals.

Hospital Ownership and Community Benefit: Looking beyond Uncompensated Care

EXECUTIVE SUMMARY Not‐for‐profit (NFP) hospitals have come under increased public scrutiny for management practices that are inconsistent with their charitable focus. Of particular concern is the amount of community benefit provided by NFP hospitals compared to for‐profit (FP) hospitals given the substantial tax benefits afforded to NFP hospitals. This study examines hospital ownership and community benefit provision beyond the traditional uncompensated care comparison by using broader measures of community benefit that capture charitable services, community assessment and partnership, and community‐oriented health services. The study sample includes 3,317 nongovernment, general, acute care, community hospitals that were in operation in 2006. Data for this study came from the 2006 American Hospital Association Hospital Survey and the 2006 Area Resource File. We used multivariate regression analyses to examine the relationship between hospital ownership and five indicators of community benefit, controlling for hospital characteristics, market demand, hospital competition, and state regulations for community benefit. We found that NFP hospitals report more community benefit activities than do FP hospitals that extend beyond uncompensated care. Our findings underscore the importance of defining and including activities beyond uncompensated care when evaluating community benefit provided by NFP hospitals.

Ohio Appalachian Women’s Perceptions of the Cost of Cervical Cancer Screening

Despite evidence of the importance of cervical cancer screening, screening rates in the United States remain below national prevention goals. Women in the Appalachia Ohio region have higher cervical cancer incidence and mortality rates along with lower cancer screening rates. This study explored the expectations of Appalachian Ohio women with regard to Papanicolaou (Pap) test cost and perceptions of cost as a barrier to screening.