Increasing the Relevance of Health Care Organizational Research

1. Increasing the Relevance of Health Care Organizational Research Jeff Alexander, Ph.D. AHRQ Annual Meeting Sept 8, 2008

2. The Problem Evidence-Based Management (EBM) is the systematic application of the best available evidence, particularly well-conducted management research, to the evaluation of managerial strategies for improving the performance of health services organizations. based on arguments that demands for high quality care and lower costs in health care can only be achieved if the management of health care organizations engages in practices that have a strong evidentiary base - that is, where the relationships between management practice and positive outcomes have been subjected to careful empirical study and confirmation. based on arguments that demands for high quality care and lower costs in health care can only be achieved if the management of health care organizations engages in practices that have a strong evidentiary base - that is, where the relationships between management practice and positive outcomes have been subjected to careful empirical study and confirmation.

3. gap exists between this ideal and the current state of the art in evidence-based management articles are often inaccessible Focus on research, not practice implications �popular� management books and journals confuse the issue Research timeframe makes info obsolete

4. AHRQ Study What new data/variables should be added to the HCUP data to increase capacity for organization and management research? Interviews with hospital and health system leaders Interviews with leading researchers Critical review of the literature Our analysis focused on two groups of questions from the interviews: current and future challenges facing hospitals as they relate to hospital quality, costs, and efficiency, and potential solutions to those challenges. Hospital CEOs were asked to identify the five most important factors contributing to quality, cost, and efficiency, the degree of control exercised over these factors by hospital staff, and whether these factors operated independently of each other. Respondents were also asked to provide specific examples where changes in these factors had a positive or negative effect on quality, cost, or efficiency. Our analysis focused on two groups of questions from the interviews: current and future challenges facing hospitals as they relate to hospital quality, costs, and efficiency, and potential solutions to those challenges. Hospital CEOs were asked to identify the five most important factors contributing to quality, cost, and efficiency, the degree of control exercised over these factors by hospital staff, and whether these factors operated independently of each other. Respondents were also asked to provide specific examples where changes in these factors had a positive or negative effect on quality, cost, or efficiency.

5. Findings research evidence is not consistent with the problems and decision-making conditions faced by those who might utilize this evidence. results of this study reveal not just gaps, but a chasm between what healthcare executives are concerned about in their daily practices and what health service research could have offered.

6. Content Evidence is lacking in a number of areas that are of top priorities to managers safe staffing level and optimal skill mix eliminating practice variation cost and quality effects of different IT systems Cost-benefit of medical technology what constitutes effective organizational culture and leadership identification of appropriate staffing volume and mix to enhance quality while reducing cost was one of the few areas explicitly identified by respondents where they thought health services research could provide useable information. need to eliminate local and national practice variation by practicing only evidence-based medicine instead of allowing physicians to maintain past practice patterns simply because �they have always been doing it that way.� Although interviewees generally felt that evidence-based protocols are widely available, the more difficult part of the process was effectively implementing the protocols. identification of appropriate staffing volume and mix to enhance quality while reducing cost was one of the few areas explicitly identified by respondents where they thought health services research could provide useable information. need to eliminate local and national practice variation by practicing only evidence-based medicine instead of allowing physicians to maintain past practice patterns simply because �they have always been doing it that way.� Although interviewees generally felt that evidence-based protocols are widely available, the more difficult part of the process was effectively implementing the protocols.

7. Approach Hospital CEOs view cost, quality, and efficiency as inextricably linked Hospital CEOs think about organizational factors systemically, not individually Hospital CEOs emphasized process related factors rather than structural drivers of cost, quality, and efficiency. When asked about the five most important contributors to cost, quality, and efficiency, most of the CEOs suggest that it would not be beneficial to focus on one or even two as levers for change. Most often, the CEO respondents indicate that changes must occur in all four or five of the areas mentioned because they are designed to be mutually reinforcing. These observations suggest that researchers need to take a more systematic and complex view of hospitals and other healthcare organizations. Instead of isolating individual aspects of performance and contributing factors, researchers should explore alternative conceptual models that are more aligned with how hospital leaders view their organizations and the interplay of various organizational/management factors. When asked about the five most important contributors to cost, quality, and efficiency, most of the CEOs suggest that it would not be beneficial to focus on one or even two as levers for change. Most often, the CEO respondents indicate that changes must occur in all four or five of the areas mentioned because they are designed to be mutually reinforcing. These observations suggest that researchers need to take a more systematic and complex view of hospitals and other healthcare organizations. Instead of isolating individual aspects of performance and contributing factors, researchers should explore alternative conceptual models that are more aligned with how hospital leaders view their organizations and the interplay of various organizational/management factors.

8. Are We Asking the Right Questions? All organizations are not alike Middle ground between individually tailoring approaches and one size fits all formulas Conditional effects of strategies, innovations, or changes

9. Meeting Customer Needs Practice leaders do not consider health services research a part of their information armamentarium improved understanding of the cognitive maps that managers use in both defining problems and developing solutions what are the decision-making constraints faced by managers? What criteria form the basis for selecting among alternative strategies? How are particular solutions adapted to fit different circumstances?

10. Opportunities How can systems of accountability be designed to ensure adequate coordination across organizational boundaries and providers of care ? How can clinical teams be organized and led to achieve better results for patients? What are the organizational and behavior responses to different incentive programs such as P4P ?

11. Opportunities How can organizations promote the diffusion, implementation and sustainability of new, evidence based practices? Are new care models effective in terms of improving quality, and efficient in terms of reducing costs (patient centered medical home)

12. Threats and Barriers Timing Formulating our problems in isolation Insufficient interdisciplinary research traditional structures and incentive systems in universities Funding

13. Data Issues Existing data does not address many of the problems managers regard as important Structure not process primary data collection small sample sizes perceived lack of generalizability of findings