Change In Healthcare Organizations Research Articles

Transforming primary healthcare by including the stakeholders involved in delivering care to people living in poverty: EQUIhealThY study protocol.

BackgroundEnsuring access to timely and appropriate primary healthcare for people living in poverty is an issue facing all countries, even those with universal healthcare systems. The transformation of healthcare practices and organization could be improved by involving key stakeholders from the community and the healthcare system in the development of research interventions. The aim of this project is to stimulate changes in healthcare organizations and practices by encouraging collaboration between care teams and people living in poverty. Our objectives are twofold: 1) to identify actions required to promote the adoption of professional practices oriented toward social competence in primary care teams; and 2) to examine factors that would encourage the inclusion of people living in poverty in the process of developing social competence in healthcare organizations.Methods/designThis study will use a participatory action research design applied in healthcare organizations. Participatory research is an increasingly recognized approach that is helpful for involving the people for whom the research results are intended. Our research team consists of 19 non-academic researchers, 11 academic researchers and six partners. A steering committee composed of academic researchers and stakeholders will have a decision-making role at each step, including knowledge dissemination and recommendations for new interventions. In this project we will adopt a multiphase approach and will use a variety of methods, including photovoice, group discussions and interviews.DiscussionThe proposed study will be one of only a few using participatory research in primary care to foster changes aimed at enhancing quality and access to care for people living in poverty. To our knowledge this will be the first study to use photovoice in healthcare organizations to promote new interventions. Our project includes partners who are targeted for practice changes and improvements in delivering primary care to persons living in poverty. By involving knowledge users, including service recipients, our study is more likely to produce a transformation of professional practices and encourage healthcare organizations to take into account the needs of persons living in poverty.

Evaluating interventions to improve somatic health in severe mental illness: a systematic review

To present a systematic review of the evaluation of randomized interventions directed toward improving somatic health for patients with severe mental illness (SMI). A systematic search in PubMed, Embase, Cinahl, and PsycInfo was performed. The scope of the search was prospective studies for patients aged 18-70, published from January 2000 till June 2011. Randomized interventions directed toward improving somatic health for patients with SMI were selected. We excluded studies on elderly, children, and studies performed before 2000. Information on population, type of intervention, follow-up, outcome measures, and on authors' conclusions were drawn from the original articles. Twenty-two original studies were included, presenting four types of interventions: health education (n = 9), exercise (n = 6), smoking cessation (n = 5), and changes in health care organization (n = 2). To evaluate the effect of these studies 93 different outcome measures were used in 16 categories. Many interventions directed toward improving somatic health for patients with SMI have been started. These studies did not apply similar evaluations, and did not use uniform outcome measures of the effect of their interventions. Valuable comparisons on effectiveness are therefore almost impossible.

Leadership and transformational change in healthcare organisations: a qualitative analysis of the North East Transformation System.

The research project 'An Evaluation of Transformational Change in NHS North East' examines the progress and success of National Health Service (NHS) organisations in north east England in implementing and embedding the North East Transformation System (NETS), a region-wide programme to improve healthcare quality and safety, and to reduce waste, using a combination of Vision, Compact, and Lean-based Method. This paper concentrates on findings concerning the role of leadership in enabling tranformational change, based on semi-structured interviews with a mix of senior NHS managers and quality improvement staff in 14 study sites. Most interviewees felt that implementing the NETS requires committed, stable leadership, attention to team-building across disciplines and leadership development at many levels. We conclude that without senior leader commitment to continuous improvement over a long time scale and serious efforts to distribute leadership tasks to all levels, healthcare organisations are less likely to achieve positive changes in managerial-clinical relations, sustainable improvements to organisational culture and, ultimately, the region-wide step change in quality, safety and efficiency that the NETS was designed to deliver.

The Role of Sensemaking in Constructing Agents of Change

The use of agents to facilitate change in healthcare organisations is widely advocated. Organisational literature distinguishes between a variety of different types of agents (champions, opinion leaders and change agents), but we know little about how this distinction is implemented in practice and how different organisational members make sense of the role. Using sensemaking theories we study a case of large-scale organisational change and consider how senior managers, middle managers, and agents sensemake and enact change facilitating roles. We examine how this process determines successful organisational outcomes. We found that when new agent roles are accompanied by ambiguous managerial sensegiving, the accompanying sensemaking was dispersed and subsequently front-line role enactment was less effective. This suggests that for successful change senior management need to clearly distinguish the definitions and boundaries of this role.

The Evolution of Knowledge Exchanges Enabling Successful Practice Change in Two Intensive Care Units

Many hospitals are unable to successfully implement evidence-based practices. For example, implementation of the central line bundle (CLB), known to prevent catheter-related bloodstream infections (CRBSIs) is often challenging. This problem is broadly characterized as “change implementation failure.” The theoretical literature on organizational change has suggested that periodic top-down communications promoting tacit knowledge exchanges across professional subgroups may be effective for enabling learning and change in healthcare organizations. However, gaps remain in understanding the mechanisms by which top-down communications enable practice change at the unit level. A prospective study was conducted in two intensive care units within an academic health center. Both units had low baseline adherence to CLB and higher-than-expected CRBSIs. Periodic top-down quality improvement communications were conducted over a 52-week period to promote CLB implementation in both units. Simultaneously, the study examined: 1) the content and frequency of communication related to CLB in both units through weekly “communication logs” completed by physicians, nurses, and managers; and 2) unit outcomes, i.e., CLB adherence rates through weekly chart reviews. Both units experienced substantially improved outcomes, including increased adherence to CLB, and statistically significant (sustained) declines in catheter utilization and CRBSIs. The study examines associations between communication content & frequency and outcomes, and describes the evolution of knowledge exchanges at the unit level. Findings provide insight into key unit-level variables enabling change. The study helps develop: 1) a theoretical framework on effective communication content & frequency for practice change, and 2) evidence-based management strategies for successful practice change at the unit level.

Managing boundaries in primary care service improvement: a developmental approach to communities of practice.

BackgroundEffective implementation of change in healthcare organisations involves multiple professional and organisational groups and is often impeded by professional and organisational boundaries that present relatively impermeable barriers to sharing knowledge and spreading work practices. Informed by the theory of communities of practice (CoPs), this study explored the effects of intra-organisational and inter-organisational boundaries on the implementation of service improvement within and across primary healthcare settings and on the development of multiprofessional and multi-organisational CoPs during this process.MethodsThe study was conducted within the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester—a collaborative partnership between the University of Manchester and local National Health Service organisations aiming to undertake applied health research and enhance its implementation in clinical practice. It deployed a qualitative embedded case study design, encompassing semistructured interviews, direct observation and documentary analysis, conducted in 2010–2011. The sample included practice doctors, nurses, managers and members of the CLAHRC implementation team.FindingsThe study showed that in spite of epistemic and status differences, professional boundaries between general practitioners, practice nurses and practice managers co-located in the same practice over a relatively long period of time could be successfully bridged, leading to the formation of multiprofessional CoPs. While knowledge circulated relatively easily within these CoPs, barriers to knowledge sharing emerged at the boundary separating them from other groups existing in the same primary care setting. The strongest boundaries, however, lay between individual general practices, with inter-organisational knowledge sharing and collaboration between them remaining unequally developed across different areas due to historical factors, competition and strong organisational identification. Manipulated emergence of multi-organisational CoPs in the context of primary care may thus be problematic.ConclusionsIn cases when manipulated emergence of new CoPs is problematic, boundary issues could be addressed by adopting a developmental perspective on CoPs, which provides an alternative to the analytical and instrumental perspectives previously described in the CoP literature. This perspective implies a pragmatic, situational approach to mapping existing CoPs and their characteristics and potentially modifying them in the process of service improvement through the combination of internal and external facilitation.

The Impact of HCAʼs 2006 Leveraged Buyout on Hospital Performance

Leveraged buyout (LBO) arrangements are a reorganization strategy whereby a firm assumes a substantial amount of debt to buy back its publicly held stock to become privately held. LBOs offer a firm several advantages and have the potential to increase efficiency. In the past 20 years, several healthcare firms have engaged in LBOs, but the literature on performance changes in healthcare organizations as a result of an LBO is limited. In this article, we report on a study that examined the performance of Hospital Corporation of America (HCA) hospitals before and after the LBO that was initiated in 2006. We used data from the Medicare Hospital Cost Report Information System and analyzed data from 130 HCA hospitals and 490 comparison hospitals. Findings show that HCA hospitals reduced expenses and their number of full-time equivalents (FTEs) relative to local competitor hospitals. HCA hospitals' cash-flow-margin ratio was substantially higher when adjusted for its local competing hospitals at the beginning of the LBO as well as at end of the LBO. When compared to local hospitals, HCA hospitals had a significant decrease in their capital investment in fixed assets from 2006 to 2009. These findings underscore the effectiveness of HCA's management strategies to repay debt and increase the value of the company, and they are informative for healthcare firms and their managers who are considering LBOs.

With Great Data Comes Great Responsibility

With Great Data Comes Great Responsibility

The Contribution of Hospital Nursing Leadership Styles to 30-day Patient Mortality

Nursing work environment characteristics, in particular nurse and physician staffing, have been linked to patient outcomes (adverse events and patient mortality). Researchers have stressed the need for nursing leadership to advance change in healthcare organizations to create safer practice environments for patients. The relationship between styles of nursing leadership in hospitals and patient outcomes has not been well examined. The purpose of this study was to examine the contribution of hospital nursing leadership styles to 30-day mortality after controlling for patient demographics, comorbidities, and hospital factors. Ninety acute care hospitals in Alberta, Canada, were categorized into five styles of nursing leadership: high resonant, moderately resonant, mixed, moderately dissonant, and high dissonant. In the secondary analysis, existing data from three sources (nurses, patients, and institutions) were used to test a hypothesis that the styles of nursing leadership at the hospital level contribute to patient mortality rates. Thirty-day mortality was 7.8% in the study sample of 21,570 medical patients; rates varied across hospital categories: high resonant (5.2%), moderately resonant (7.4%), mixed (8.1%), moderately dissonant (8.8%), and high dissonant (4.3%). After controlling for patient demographics, comorbidities, and institutional and hospital nursing characteristics, nursing leadership styles explained 5.1% of 72.2% of total variance in mortality across hospitals, and high-resonant leadership was related significantly to lower mortality. Hospital nursing leadership styles may contribute to 30-day mortality of patients. This relationship may be moderated by homogeneity of leadership styles, clarity of communication among leaders and healthcare providers, and work environment characteristics.

The Practice of Leadership in the Messy World of Organizations

This article examines the practice of leadership in organizations characterized by ambiguous authority relationships. Drawing on three empirical case studies illustrative of a long-term research program on change in health care organizations, we examine leadership as a practical activity focusing particularly on its dynamic, collective, situated, and dialectical nature. We invite researchers on leadership to look carefully at the embeddedness of leadership roles in context and at the type and consequences of practices that leaders develop in such contexts. Implications of these ideas for further research and for would-be leaders are discussed.

‘If we can't do more, let's do it differently!': using appreciative inquiry to promote innovative ideas for better health care work environments

To examine the use of appreciative inquiry to promote the emergence of innovative ideas regarding the reorganization of health care services. With persistent employee dissatisfaction with work environments, experts are calling for radical changes in health care organizations. Appreciative inquiry is a transformational change process based on the premise that nurses and health care workers are accumulators and producers of knowledge who are agents of change. A multiple embedded case study was conducted in two interdisciplinary groups in outpatient cancer care to better understand the emergence and implementation of innovative ideas. The appreciative inquiry process and the diversity of the group promoted the emergence and adoption of innovative ideas. Nurses mostly proposed new ideas about work reorganization. Both groups adopted ideas related to interdisciplinary networks and collaboration. A forum was created to examine health care quality and efficiency issues in the delivery of cancer care. This study makes a contribution to the literature that examines micro systems change processes and how ideas evolve in an interdisciplinary context. The appreciative inquiry process created an opportunity for team members to meet and share their successes while proposing innovative ideas about care delivery. Managers need to support the implementation of the proposed ideas to sustain the momentum engendered by the appreciative inquiry process.

Health Federalism: The Role of Health Care Professionals in Nepal

Nepal has entered from its unitary system into a new "Federal Democratic Republic State". The current constitution presents basic health care services as a fundamental right. The Ministry for Health and Population has been providing resources to meet health demands, but managers are wrestling to meet these demands. Persistent disparities between rural and urban and across regions resulted inferior health outcomes, e.g., life expectancy in an urban district like Bhaktapur is 71 years, whereas in the rural district of Mugu it is 44 years. The poor health and poor access to health care in the past systems prompted people to seek a different model. Ultimately, all political parties except one have agreed on federalism. The exact number of federal states that are going to be created is unknown. In federalism, all federated states have to assume certain relationships between the locality, the region, and the nation that apply not only in politics but in health care too. Managing changes in health care organization during the transitional period and after restructuring the unitary Nepal into federal states should be carefully planned. In case, if new system also fails to deliver necessary health care services, the possibility of igniting of dissatisfaction, public unrest and even disintegration cannot be ignored. In order to outline a structure and give life to a health care system under federalism, health care professionals need to engage themselves seriously.

Using an action research process in pharmacy practice research—A cooperative project between university and internship pharmacies

Background Action research (AR) is a common research-based methodology useful for development and organizational changes in health care when participant involvement is key. However, AR is not widely used for research in the development of pharmaceutical care services in pharmacy practice. Objectives To disseminate the experience from using AR methodology to develop cognitive services in pharmacies by describing how the AR process was conducted in a specific study, and to describe the outcome for participants. Methods The study was conducted over a 3-year period and run by a steering group of researchers, pharmacy students, and preceptors. The study design was based on AR methodology. The following data production methods were used to describe and evaluate the AR model: documentary analysis, qualitative interviews, and questionnaires. Results Experiences from using AR methodology and the outcome for participants are described. A set of principles was followed while the study, called the Pharmacy-University study, was being conducted. These principles are considered useful for designing future AR studies. Outcome for participating pharmacies was registered for staff-oriented and patient-oriented activities. Outcome for students was practice as project leaders and enhancement of clinical pharmacy-based skills. Outcome for researchers and the steering group conducting the study was in-depth knowledge of the status of pharmacies in giving advice to patient groups, and effective learning methods for students. Conclusion Developing and implementing cognitive pharmaceutical services (CPS) involves wide-reaching changes that require the willingness of pharmacy and staff as well as external partners. The use of AR methodology creates a platform that supports raising the awareness and the possible inclusion of these partners. During this study, a set of tools was developed for use in implementing CPS as part of AR.

Predictors of self-assessed physical and mental health of Icelandic nurses: Results from a national survey

Background Recent health care organizational changes have been associated with stress and musculoskeletal disorders in nurses. However, studies are lacking on what factors are the most important predictors of poor self-assessed health among nurses. Objectives To describe and identify the self-assessed predictors of physical and mental health of nurses. Participants and design A cross-sectional design was used with a sample of 394 nurses, drawn from the registry of the Icelandic Nurses’ Association, representing 17% of the workforce of Icelandic nurses. Methods Data were collected with a self-administered questionnaire, addressing symptoms, illness and treatment, lifestyle and sleep, work and working environment, family and quality of family life. Data were analysed according to nurses’ assessment of their physical and mental health (very good/good; poor/very poor) by use of analysis of variance, chi-square and stepwise multiple linear regression. Results 21.7% of participants assessed their physical health as poor or very poor and 14.3% assessed their mental health as such. Those who assess their physical or mental health poor/very poor, as compared to the others, reported more symptoms in general, less regular exercise, as well as more use of medication, more visits to physicians, trouble with sleeping, conflicts between work and family life, work absence, and they experience their work as more strenuous. Experiencing symptoms is an important predictor of both physical and mental health of nurses. Conclusion Various factors, including work-, family- and socio-cultural environment, play a role in how nurses assesses their health. During our present time of nurse shortage it is imperative that the authorities take special measures in order to improve the work environment of nurses.

The role and characteristics of a manager in the strategic transformation of the health care system

Introduction: Global markets and competition, fast changes, the explosion of information technology, integration processes in international relations are some of the initial factors for changes in health care organizations and their management. Management represents an evolving new generic function of all organizations of social significance across the world. Managers in the health sector have exceptionally complex roles that require new skills and methods. The objective of this study is to analyze in grater detail, explain and describe the role and necessary skills of a health care manager in the strategic transformation of health care management. The modern health care manager can get the best results by strengthening human resources and meeting employees' personal needs in accordance with the global and specific goals of the health care institution. The manager is at the same time a mentor and a facilitator, putting to best use the forementioned transformation strategies whilst expending the resources carefully, strengthening the collective efforts, involving employees in the decision-making process and motivating teamwork and collective problem-solving.

Exploring the effectiveness of action research as a tool for organizational change in health care

This paper acknowledges the similarities between action research and successful strategies for planned organizational change, and uses an action research case study to explore the extent to which democratic and participatory approaches to organizational change, such as action research, can flourish in a context of externally imposed targets, as is characteristic of the UK National Health Service. Using case study findings, the authors claim that some practice changes are possible, but that locally devised targets may not be achievable if managers' attention is distracted by other priorities or if targets are in conflict with externally set targets. The authors emphasise the value of engaging managers as well as practitioners in action research, and identify that an action research approach not only has the potential for positive organizational change, but can also provide a unique data set on how central policy translates into practice and patient outcomes. Whether or not planned change occurs, with action research there is always potential for new understandings to emerge.

Review: Exploring the effectiveness of action research as a tool for organizational change in health care

Review: Exploring the effectiveness of action research as a tool for organizational change in health care

The VHA New England Medication Error Prevention Initiative as a Model for Long-Term Improvement Collaboratives

Quality improvement collaboratives (QICs) are a widely applied strategy for implementing change in health care organizations. Alternative collaborative methodologies were compared to gain insight into the elements important for QIC success. A modified version of a previously described QIC evaluation tool was used to assess the methods and characteristics of the Medication Error Prevention Initiative (MEPI) and to compare MEPI with two other long-term ongoing QICs--the Vermont-Oxford Network's Neonatal Intensive Care QIC and the Northern New England Cardiovascular Disease Study Group, and the shorter-term Breakthrough Series QICs of the Institute for Healthcare Improvement (IHI). The modified QIC assessment tool was a useful framework for QIC assessment and comparison. The MEPI differed in scope of topic, team members, and the method for learning about and making improvements. Long-term QIC methods such as those used by MEPI may be particularly applicable when QICs address broad, complex, comprehensive, or organizationwide improvement needs.

Transforming Healthcare Organizations

Change in healthcare organizations is a complex task often fraught with unforeseen challenges. Based on the experiences of a multi-site hospital, and drawing on past research on organizational change, the author provides a model to help change leaders. Although relying on Toronto's University Health Network to illustrate the change model, the model is intended to speak to change leaders implementing various types of complex changes across a range of organizations.

Using Evidence and Process Improvement Strategies to Enhance Healthcare Outcomes for the Critically Ill: A Pilot Project

Although the value of evidence-based practice may seem obvious, the process needed to produce more effective delivery of evidence-based healthcare is not obvious. Furthermore, the continuing escalation of healthcare costs fuels the desire of providers and consumers to undertake only those treatments that have benefit. One way to effect necessary changes in healthcare organizations is through focused, interdisciplinary, collaborative projects related to evidence-based practice. To reduce rates of ventilator-associated pneumonia and catheter-related bloodstream infection in patients in the medical intensive care unit of a large, urban tertiary referral hospital in the Southwest. The theory of planned behavior served as the basis for providing staff members with research-based, easily controllable strategies that "fit" with the usual methods of care delivery. Implementation of the strategies and data collection were accomplished through routine rounds on patients and regular reporting of objective information. During a 15-month period, use of the selected strategies resulted in a 54% reduction in ventilator-associated pneumonia, a 78% reduction in catheter-related bloodstream infections, and a 18% reduction in mean length of stay in the unit. Use of a multidisciplinary, environmentally tailored approach to concerns about patients' care resulted in estimated cost savings of 1.0 million US dollars to 2.3 million US dollars. Early, consistent communication about the project's rationale, expected behavior, and outcomes enhanced the manageability and effectiveness of this change in an adult intensive care unit.