# Presentation: 534967

## Exploring the quality chasm with organizational theory

**13****th**** Annual NRSA Trainees Research Conference **
**June 2, 2007**

**Professor Jon Chilingerian, Ph.D.**

*Pre-Doctoral Program Supported by AHRQ Training Grant*

## Design Variables & Key Processes

**PEOPLE:**

**Work:**

**Formal Arrangements**

**Culture & Values**

**Key Organizational Processes**

- Leadership & Career Development
- Decision Making
- Communication
- Coordination
- Change Management
- Strategic Planning & Management** **Control
- Performance Management** **

- Norms, Values, Assumptions
- Communication patterns
- Political Alignments** **
- Power & Influence
- Leader behaviors
- Decision Rights

- Coordination Mechanisms
- Division of Labor
- Operating systems** **
- HR Policies & Practices
- Physical Space

- Technological Complexity & Uncertainty
- Intrinsic Motivation
- Roles & Responsibilities
- Work Methods

- Task Related Competencies
- Commitment  & Motivation
- Individual Needs
- Diversity

***Design Variables & Key Processes***

## Professional Behavior

**Professional Behavior**

**financial incentives**

**care teams**

**SOPs**

**verbal requests**

**protocols**

**training & CME**

**malpractice  costs**

**colleagues**

**patient needs & requests**

**norms**

**prior socialization**

## Understanding the Quality Problem

- Diagnosis and analysis runs to the heart of the quality problem in health care...But
- There are too many organizational variables and never enough observations to predict anything precisely
- Although system, structures, and process behavior can reduce some of the quality variations, professionals can overcome most influences and management controls.

## Organizational exploration of the quality chasm

- Quality is one of the most complex problems in Health Care
- We believe that theory is important to understanding quality
- So far, we  have not found a theoretically correct way to assess and analyze quality
- Absent a guiding theory, one can think about quality from multiple social science perspectives
- Lack of widely accepted definitions
- Organizational theory offers many ways to look at and think about quality and it is critical that rival theories are pitted one against another.
- And Organizational theory will help us to craft new ideas and hypotheses about quality

## POLICY ENVIRONMENT Payment and finance system

- ORGANIZATION OF PROVIDERS & CARE PROGRAMS

- SOCIAL ENVIRONMENT Norms and values

- CLINICAL PROVIDERS

- PATIENTS

- Micro-care processes

- Micro-care processes

- Micro-care processes

- Micro-care processes

- Micro-care processes

- RELATIONSHIPS & CO-PRODUCTION

- LEADERSHIP

- FIRM

- Micro-care processes

- SELECTIVE RECRUITMENT & COMMITMENT TO GOALS

- STRATEGY & MARKETING

## POLICY ENVIRONMENT Payment and finance system

- ORGANIZATION OF PROVIDERS & CARE PROGRAMS

**POLICY ENVIRONMENT Payment and finance system**

- CLINICAL PROVIDERS

- PATIENTS

**FIRM**

## The utility of process performance measurement for Medicare value based purchasing

- Andrew Ryan

**Notes:**
Outline of presentation: Presentation will address quality performance measurement in the context of value-based purchasing in Medicare.  Specifically, it will examine the utility of process performance measures to determine quality of care for AMI and heart failure.
Quality measurement has become increasingly important in light of the IOM reports. Also, in order for a health care market knowledge about healthcare value is essential. This comes from quality and cost information together. Thus, quality must be appropriately measured for public quality reporting and financial incentives for quality to be effective.

## POLICY ENVIRONMENT Payment and finance system

- CLINICAL PROVIDERS

- PATIENTS

- LEADERSHIP

- FIRM

- SELECTIVE RECRUITMENT & COMMITMENT TO GOALS

## Exploring Substance Abuse Treatment Centers

** ****Sayeda Haq**

**Improving Quality by Aligning physicians**

## Micro-care processes

- ORGANIZATION OF PROVIDERS & CARE PROGRAMS

- CLINICAL PROVIDERS

- PATIENTS

- LEADERSHIP

- FIRM

## Increasing Performance with More Effective Coordination

- Farbod N. Hagigi, MPH, Ph.D. Candidate

## SOCIAL ENVIRONMENT Norms and values

**SOCIAL ENVIRONMENT Norms and values**

- CLINICAL PROVIDERS

**PATIENTS**

- RELATIONSHIPS & CO-PRODUCTION

- FIRM

## Using Fair Process to Cross the Quality and Healthcare Chasm:

**Eliciting the Perspective of Traumatic Brain Injury Survivors**

**Laura S. Lorenz, MA, MEd, PhD Candidate**
**Schneider Institute for Health Policy,**
**The Heller School for Social Policy and Management,**
**Brandeis University**

## POLICY ENVIRONMENT Payment and finance system

- ORGANIZATION OF PROVIDERS & CARE PROGRAMS

- SOCIAL ENVIRONMENT Norms and values

- CLINICAL PROVIDERS

- PATIENTS

- Micro-care processes

- Micro-care processes

- Micro-care processes

- Micro-care processes

- Micro-care processes

- RELATIONSHIPS & CO-PRODUCTION

- LEADERSHIP

- FIRM

- Micro-care processes

- SELECTIVE RECRUITMENT & COMMITMENT TO GOALS

- STRATEGY & MARKETING

## Care Coordination for Seniors with Multiple Chronic Diseases-

**Examining the Macro and Micro Level Relationships and Outcomes**

**Marian Ryan, RRT, MPH, CHES**
**Schneider Institute for Health Policy,**
**The Heller School for Social Policy and Management,**
**Brandeis University**

## People, Process & Authority Relations

- Hawthorne effect

- Interaction hypothesis

- Cross-pressure hypothesis

- Participation hypothesis

- PEOPLE

- Morale & productivity

- Performance

- Rapid changes in human behavior

- Frustration & withdrawal

- +

- +

- +

- +

- _

- -

- +

- +

- +

## Slide 18

**Notes:**
The Schneider Institute for Health Policy has achieved national recognition as a leading health care policy and research institution. Since its establishment in 1978, the Schneider Institute has conducted research, policy analysis, and technical assistance on issues of organization, delivery, regulation, and financing of the U.S. and selected international health care systems. In line with its collaborative approach in addressing health care system problems, the Institute works with other academic and health service research organizations, as well as with service delivery systems that serve as laboratories for demonstrating and testing new financial and delivery strategies. The Institute comprises three major divisions - Health Services Research, Policy Development and Implementation, and Technology and Organizational Change - which investigate a range of health care concerns: finance and reimbursement, state and local policies, vulnerable populations, diversity and long-term care for elders, substance abuse, and program evaluation. support for research undertaken by the Institute is provided by federal and state grants and contracts, corporations, and private foundations. 
Since its founding as Brandeis University's first professional school in 1959, The Heller School has been committed to developing new knowledge and insights in the field of social policy. Through the education of students and pursuit of research, Heller is actively engaged in examining policies and practices that respond to the changing needs of vulnerable individuals and social groups in our society. 
The Heller School offers four graduate programs:  the Ph.D. in Social Policy, the M.B.A. in Mission-Driven Management, the M.A. in Sustainable International Development, and the M.S. in International Health Policy and Management.
Heller is home to three research institutes:  the Schneider Institute for Health Policy, the Institute on Assets and Social Policy, and the Institute for Child, Youth, and Family Policy. The School has pioneered in a variety of policy areas including health; mental health; substance abuse; children, youth, and families; aging; international and community development; mental retardation and developmental disabilities; poverty and hunger; and work and inequalities. All Heller research strives to close the gap between theory and practice.
Having recently celebrated its 45th anniversary, The Heller School is committed to knowledge advancing social justice and will keep the concept of human health and well-being in the forefront of the public conscience. 

## What is the Motivating Context: Strong/Weak/Distorted?

- Payment & Finance
- Professional Norms
- Leadership Behavior
- Grouping of Units
- Performance Standards
- Reward Systems
- Recruitment/Training
- Management Control/Operating Systems
- Political System and Decision Rights
- Values and Norms

## Organizational Views on Quality

- _High Reliability_
- Safety culture
- Decentralize DM
- Good design
- Redundancy
- Trial and error and simulations

- _Normal Accidents_
- Safety one of many competing objectives
- Redundancy causes problems
- Decentralization needed for complexity; however centralization needed for loosely coupled systems