Stephen M. Shortell

Customization or Conformity? an Institutional and Network Perspective on the Content and Consequences of TQM Adoption

The authors thank Rakesh Khurana, Mark Shanley, and Edward Zajac for valuable comments on earlier versions of this paper. The paper has also benefited from the helpful comments of Christine Oliver and three anonymous reviewers for ASQ, as well as the editorial assistance of Linda Johanson. The following groups provided data used in this study: The AHA Hospital Research and Educational Trust, the AHA Data Survey Group, the Joint Commission on Accreditation of Health Care Organizations, and the Health Care Investment Analysts. We also thank the Baxter Foundation and the Graduate Program in Health Services Management at the Kellogg Graduate School of Management for generously funding this research. Additional support was provided by the A.C. Buehler Chair in Health Services Management at the Kellogg School. An earlier version of the paper received the 1996 West Press Best Paper Award in the Organization and Management Theory Division of the Academy of Management. This study develops a theoretical framework that integrates institutional and network perspectives on the form and consequences of administrative innovations. Hypotheses are tested with survey and archival data on the implementation of total quality management (TQM) programs and the consequences for organizational efficiency and legitimacy in a sample of over 2,700 U.S. hospitals. The results show that early adopters customize TQM practices for efficiency gains, while later adopters gain legitimacy from adopting the normative form of TQM programs. The findings suggest that institutional factors moderate the role of network membership in affecting the form of administrative innovations adopted and provide strong evidence for the importance of institutional factors in determining how innovations are defined and implemented. We discuss implications for theory and research on institutional processes and network effects and for the literatures on innovation adoption and total quality management.*

Improving the quality of health care in the United Kingdom and the United States: a framework for change.

Fueled by public incidents and growing evidence of deficiencies in care, concern over the quality and outcomes of care has increased in both the United Kingdom and the United States. Both countries have launched a number of initiatives to deal with these issues. These initiatives are unlikely to achieve their objectives without explicit consideration of the multilevel approach to change that includes the individual, group/team, organization, and larger environment/system level. Attention must be given to issues of leadership, culture, team development, and information technology at all levels. A number of contingent factors influence these efforts in both countries, which must each balance a number of tradeoffs between centralization and decentralization in efforts to sustain the impetus for quality improvement over time. The multilevel change framework and associated properties provide a framework for assessing progress along the journey.

THE PERFORMANCE OF INTENSIVE CARE UNITS : DOES GOOD MANAGEMENT MAKE A DIFFERENCE ?

A significant portion of health care resources are spent in intensive care units with, historically, up to two-fold variation in risk-adjusted mortality. Technological, demographic, and social forces are likely to lead to an increased volume of intensive care in the future. Thus, it is important to identify ways of more efficiently managing intensive care units and reducing the variation in patient outcomes. Based on data collected from 17,440 patients across 42 ICUs, the present study examines the factors associated with risk-adjusted mortality, risk-adjusted average length of stay, nurse turnover, evaluated technical quality of care, and evaluated ability to meet family member needs. Using the Apache III methodology for risk-adjustment, findings reveal that: 1) technological availability is significantly associated with lower risk-adjusted mortality (beta = -.42); 2) diagnostic diversity is significantly associated with greater risk-adjusted mortality (beta = .46); and 3) caregiver interaction comprising the culture, leadership, coordination, communication, and conflict management abilities of the unit is significantly associated with lower risk-adjusted length of stay (beta = .34), lower nurse turnover (beta = -.36), higher evaluated technical quality of care (beta = .81), and greater evaluated ability to meet family member needs (beta = .74). Furthermore, units with greater technological availability are significantly more likely to be associated with hospitals that are more profitable, involved in teaching activities, and have unit leaders actively participating in hospital-wide quality improvement activities. The findings hold a number of important managerial and policy implications regarding technological adoption, specialization, and the quality of interaction among ICU team members. They suggest intervention “leverage points” for care givers, managers, and external policy makers in efforts to continuously improve the outcomes of intensive care.

Perceptual and Archival Measures of Miles and Snow's Strategic Types: A Comprehensive Assessment of Reliability and Validity

Despite the widespread research use of Miles and Snows typology of strategic orientations, there have been no systematic attempts to assess the reliability and validity of its various measures. The present work provides such an assessment using data collected at two points from over 400 organizations in the hospital industry. We examined dimensions of the typology using both perceptual self-typing and archival data from multiple sources. The results generally support predictions across a variety of measures. Implications for further testing and research are discussed.

Assessing the Impact of Continuous Quality Improvement on Clinical Practice: What It Will Take to Accelerate Progress

The literature on continuous quality improvement (CQI) has produced some evidence, based on nonrandomized studies, that its clinical application can improve outcomes of care while reducing costs. Its effectiveness is enhanced by a nucleus of physician involvement, individual practitioner feedback, and a supportive organizational culture. The few randomized studies, however, suggest no impact of CQI on clinical outcomes and no evidence to date of organization-wide improvement in clinical performance. Further, most studies address misuse issues and avoid examining overuse or underuse of services. The clinical application of CQI is more likely to have a pervasive impact when it takes place within a supportive regulatory and competitive environment, when it is aligned with financial incentives, and when it is under the direction of an organizational leadership that is committed to integrating all aspects of the work.

Quality collaboratives: lessons from research

Quality improvement collaboratives are increasingly being used in many countries to achieve rapid improvements in health care. However, there is little independent evidence that they are more cost effective than other methods, and little knowledge about how they could be made more effective. A number of systematic evaluations are being performed by researchers in North America, the UK, and Sweden. This paper presents the shared ideas from two meetings of these researchers. The evidence to date is that some collaboratives have stimulated improvements in patient care and organisational performance, but there are significant differences between collaboratives and teams. The researchers agreed on the possible reasons why some were less successful than others, and identified 10 challenges which organisers and teams need to address to achieve improvement. In the absence of more conclusive evidence, these guidelines are likely to be useful for collaborative organisers, teams and their managers and may also contribute to further research into collaboratives and the spread of innovations in health care.

Organizational assessment in intensive care units (ICUs): construct development, reliability, and validity of the ICU nurse-physician questionnaire.

Health Services Research has a growing need for reliable and valid measures of managerial practices and organizational processes. A national study of 42 intensive care units involving over 1,700 respondents provides evidence for the reliability and validity of a comprehensive set of measures related to leadership, organizational culture, communication, coordination, problem solving-conflict management and team cohesiveness. The data also support the appropriateness of aggregating individual respondent data to the unit level. Implications for further research are discussed.

The Patient-Centered Medical Home: Will It Stand the Test of Health Reform?

THE FUNDAMENTAL CHALLENGE FOR HEALTH CARE REform in the United States is to expand access to all US residents, while rapidly reengineering the delivery system to provide consistently high-quality care at lower overall cost. Current reform discussions recognize that success will require a shift in emphasis from fragmentation to coordination and from highly specialized care to primary care and prevention. One prominent model of delivery system reform is the patient-centered medical home (PCMH). Crafted by the primary care professional organizations in 2007, the model has been endorsed by a broad coalition of health care stakeholders, including all of the major national health plans, most of the Fortune 500 companies, consumer organizations and labor unions, the American Medical Association, and a total of 17 specialty societies. Currently, 22 multistakeholder demonstration pilot projects are under way in 14 states, and the Centers for Medicare & Medicaid Services will conduct Medicare demonstration pilot projects in 400 practices in 8 regional sites in 2009. Twenty bills promoting the PCMH concept have been introduced in 10 states.

Primary Care and Accountable Care: Two Essential Elements of Delivery-System Reform

The “patient-centered medical home” and the “accountable care organization” are two widely discussed models for delivery-system reform. Drs. Diane Rittenhouse, Stephen Shortell, and Elliott Fisher have identified several strategies for ensuring that these models are mutually reinforcing.

The Role of Perceived Team Effectiveness in Improving Chronic Illness Care

Background/Objectives:The importance of teams for improving quality of care has received increased attention. We examine both the correlates of self-assessed or perceived team effectiveness and its consequences for actually making changes to improve care for people with chronic illness. Study Setting and Methods:Data were obtained from 40 teams participating in the national evaluation of the Improving Chronic Illness Care Program. Based on current theory and literature, measures were derived of organizational culture, a focus on patient satisfaction, presence of a team champion, team composition, perceived team effectiveness, and the actual number and depth of changes made to improve chronic illness care. Results:A focus on patient satisfaction, the presence of a team champion, and the involvement of the physicians on the team were each consistently and positively associated with greater perceived team effectiveness. Maintaining a balance among culture values of participation, achievement, openness to innovation, and adherence to rules and accountability also appeared to be important. Perceived team effectiveness, in turn, was consistently associated with both a greater number and depth of changes made to improve chronic illness care. The variables examined explain between 24 and 40% of the variance in different dimensions of perceived team effectiveness; between 13% and 26% in number of changes made; and between 20% and 42% in depth of changes made. Conclusions:The data suggest the importance of developing effective teams for improving the quality of care for patients with chronic illness.