# Presentation: 183538

## What Went Right?

- Dr. Thomas Vaughn

- Please click to change to the next slide

## Why and How We Study Healthcare Organization

- What is an organization?
- “...social units (or human groupings) deliberately constructed an reconstructed to seek specific goals.” Etzioni, in Scott, 1998
- “...systems of interdependent activities linking shifting coalitions of participants; the systems are embedded in – dependent on continuing exchanges with and constituted by – the environments in which they operate.” Scott, 1998

- Please click to change to the next slide

## Why Study Them

- They are interesting phenomena
- Almost all healthcare delivered in or   thought, and regulated, financed, supplied by organizations
- Hospitals and health systems
- Physician group practices
- Nursing homes
- Pharmacies
- JCAHO
- MCOs
- CMS
- Health departments

- Please click to change to the next slide

## Why Study Them

- They are an interesting phenomena
-  A couple of numbers
- Hospitals (AHA)
- Approximately 6,000
- Community, general non-profit – 3,200
- For-profit – 1,100
- Local governmental – 1,100
- State and federal – 600 (140 or so VA)
- Group practices (MGMA, 10-6-04)
- About 11,000
- About 230,000 physicians

- Please click to change to the next slide

## Why Study Them

- Intermediary between the environment and the individual
- Despite all we hear about the problems in health care from various sources (IOM’s To Err is Human and Crossing the Quality Chasm), a lot more goes right than goes wrong
- Nevertheless, we could do a better job

- Please click to change to the next slide

## A Conceptual Framework (Donabedian)

- Sociocultural Factors

- Sociocultural Factors

- Sociocultural Factors

- Sociocultural Factors

- Sociocultural Factors

- Organizations

- Organizations

- Organizations

- Organizations

- Medical Care Process

- Need

- Client Behaviors

- Provider Behaviors

- Use of Service

- Health Outcomes
- (Modification of Need)

- Please click to change to the next slide

## A Conceptual Framework

- Environment (Macro)        Important Segments
- Economic
- Political
- Federal
- State
- Local

- Please click to change to the next slide

## A Conceptual Framework (environment)

- Cultural
- Demographics
- Health beliefs
- Health seeking behaviors
- General beliefs and expectations in our society
- Professional responsibilities and rights
- Patient/client responsibilities and rights

- Please click to change to the next slide

## A Conceptual Framework (environment)

- Competitive environment (Porter)
- Payers
- Suppliers
- Technology
- Professional and technical educators
- Materials
- Labor Pool
- Competitors
- Substitutes
- Potential entrants

- Please click to change to the next slide

## A Conceptual Framework

- Individual Actors (Micro)
- Providers
- Professionals
- Technical Staff
- Support Staff
- Patients/Clients

- Please click to change to the next slide

## A Conceptual Framework (Individual Actors)

- Sociocultural Factors

- Sociocultural Factors

- Sociocultural Factors

- Sociocultural Factors

- Sociocultural Factors

- Organizations

- Organizations

- Organizations

- Organizations

- Medical Care Process

- Providers

- Patients/Clients

- Process of Care

- Please click to change to the next slide

## A Conceptual Framework

- Organizations (Meso)
- Intervene between environment and individual actors (Thompson)
- Drive and constrain individual behavior

- Please click to change to the next slide

## What

- Structure – process – outcome (Donabedian)
- Structure or organizations and units – affected by
- Environment
- Number and type of important stakeholders
- Concentration versus fragmentation
- Munificence
- Stability
- Technology – How inputs are converted to “finished products”

- Please click to change to the next slide

- C.	Size
- Formalization
- Standardization
- Centralization
- Hierarchical levels
- D.	Culture

- Please click to change to the next slide

## What

- Processes
- More to support clinical research
- Change, adaptation

- Please click to change to the next slide

- Please click to change to the next slide

- 		4.Outcomes
- Cost
- Quality
- Technical
- Patient satisfaction
- Access
- Employee satisfaction
- Organizational change

- Please click to change to the next slide

## How – Theoretical / Conceptual Basis

- Roots
- Sociological and organizational sociology
- Psychology
- Political science

- Please click to change to the next slide

## How – Theoretical / Conceptual Basis

- Theoretical / Conceptual Paradoxes
- Micro vs. Macro level of causation
- Human behavior tends to be over-determined (Rossi)
- Levels of causation
- Rational vs. non-rational (natural) (Scott; Hawthorne studies)
- Volunaristic vs. constrained choice (free will vs. determinism)
- Stability vs. change

- Please click to change to the next slide

## How – Theoretical / Conceptual Basis

- Some major “macro” level theories
- Resource dependence (Pfeffer and Salancik)
- Operates at multiple levels, e.g. interdepartmental power, though primarily at organization
- No person or organization can be entirely self-sufficient
- Therefore interdependencies are created based on an exchange or resources

- Please click to change to the next slide

- 4. Resource exchange entails surrendering a certain amount of autonomy in order to maintain the exchange relationship
- 5.	Resource dependency studies organizational processes to manage these interdependencies an associated power differentials.

- Please click to change to the next slide

## How – Theoretical / Conceptual Basis

- Structural Contingency Theory
- Operates at the organization level, but addresses technology and human resources
- Argues there is no one way to structure an organization for maximum effectiveness
- Nor are all ways equally effective

- Please click to change to the next slide

- 	4. Effectiveness is based on matching 	the organization’s
- 			strategy,
- 			structure,
- 			technology, and
- 			human resource approach
- 		to environment and task (nature of the 	work) contingencies (Miles and Snow)

- Please click to change to the next slide

## How – Theoretical / Conceptual Basis

- Transaction cost (Willamson)
- Focuses on issues related to theory in practice
- Attempts to explain organizations as the result of “make or buy” decisions

- Please click to change to the next slide

- 3.	Four issues:
- Uncertainty (and complexity)
- Bounded rationality
- Limited partners and information impactedness
- Opportunism

- Please click to change to the next slide

- Under conditions of
- higher uncertainty,
- bounded rationality, and
- limited partners
- organizations are more likely to form;
- under the opposite conditions spot
- contracting is more likely to take place

- Please click to change to the next slide

## How – Theoretical / Conceptual Basis

- Population Ecology
- Examines organization forms at the population level
- Primary focus on the environment and conditions that predict the creation of new organizational forms and the death of existing forms
- Based on biological ecology principles

- Please click to change to the next slide

- 4.	Organizations fill some niche in terms of what they produce and the resources they need
- 5.	Under conditions of environmental change new niches are created; new organizations emerged to “exploit” the niche
- 6.	As more organizations of that type are created the niche becomes full and organizations “die”

- Please click to change to the next slide

## How – Theoretical / Conceptual Basis

- Institutional Theory (Selznick; Meyer and Rowan; DiMaggio and Powell)
- Operates at many levels: organizational field, network, organization, individual
- “Institutions consist of cognitive, normative, and regulative structures and activities that provide stability and meaning to social behavior.” Scott, 1998, pg. 133

- Please click to change to the next slide

- 3.	Meyer and Rowan (1977) refer to institutions as rationalized myths
- Myths -- widely held beliefs whose effects are based, not on the fact that we believe them, but that we “know” that everyone else does;
- Rationalized -- they take the form of rules specifying procedures necessary to accomplish a given end
- Institutions are structures and activities that become “taken for granted” as the proper approach to achieving a goal, despite that fact the mean-ends relationships are not clear

- Please click to change to the next slide

## How – Theoretical / Conceptual Basis

- Micro level tends to draw heavily on psychological theories to study issues such as:
- Job satisfaction and turnover
- Motivation
- Productivity (some might argue this is where organizational behavior has its roots)
- Leadership
- Conflict
- Decision-making
- Goals and goal setting
- Organizational culture

- Please click to change to the next slide

- A few of the theories used, or evoked
- Maslow’s hierarchy of needs
- Herzberg’s hygiene versus motivating factors
- Hackman and Oldham’s Job characteristics theory
- Role theory (From sociology and social psychology, Katz and Kahn)
- Expectancy theory (Vroom)
- Achievement theory (McLelland)

- Please click to change to the next slide

- Equity theory (Adams, Festinger)
- Goal-setting theory (Locke and Latham)
- Attribution theory (Mitchell)
- Various leadership theories
- 1.	Theory X and Theory Y (McGregor)
- 2.	Consideration and Initiating structure (Ohio State, Blake and Mouton)
- 3.	Path-goal theory (House)
- 4.	Contingency theory (Fiedler)

- Please click to change to the next slide

## How – Theoretical / Conceptual Basis

- 5.	Some, primarily older work on the relationship between the work / technology and the organizational structure
- Perrow examined predictability and variety of tasks and materials
- Galbraith argued that organizations need to be designed to best support flow of information
- Some newer work, looked at new technology (e.g. CT scanners) and structures and roles in several radiology departments
- 6. 	There is also a lot of work on teams and workgroups (future topic)

- Please click to change to the next slide

## How – Methods and Methodical Issues

- Multiple approaches to studying organizations

- Please click to change to the next slide

## How – Methods and Methodical Issues

- Data are derived from:
- Case studies
- Histories
- Archival administrative and clinical data
- Surveys
- Paper, on-site
- Mail
- Phone
- In-person interview
- On-line
- Observation

- Please click to change to the next slide

## How – Methods and Methodical Issues

- A sampler of issues related to methods:
- Cross-level analysis
- Measurement issues
- Aggregation
- Creating constructs
- Validity
- Reliability
- Scaling
- Categorical vs. ordinal vs. interval data

- Please click to change to the next slide

- c.	Biases
- Single-method
- Social desirability
- Self-serving bias
- Post hoc rationalization
- Hawthorne effect
- Heisenberg effect

- Please click to change to the next slide

## How – Methods and Methodical Issues

- Causality
- Very expensive and difficult to design a true experiment
- Post hoc ergo propter hoc
- Sampling Issues
- Size
- Representativeness
- Appropriate sampling frame
- Appropriate responses
- Weighted sampling
- Generalizability

- Please click to change to the next slide

## How – Methods and Methodical Issues

- Analysis Issues
- Small Ns often, especially for subgroup analysis
- Level of analysis
- Cross-level
- Aggregation
- Nested, clustered sample
- Missing data
- Outliers and influential cases
- Appropriate statistical procedures
- Longitudinal analysis

- Please click to change to the next slide

## Challenges to Doing Research on Organizations (Christy Lemak)

- Research, especially primary data collection is slow; management fads are fast
- Managers tend to listen to consultants rather than read research

- Please click to change to the next slide

- 3. Access
- More cooperation is the organization or individual is likely to “look good”
- Burden of collecting primary data, or digging up archival data
- HIPAA
- Other issues around confidentiality

- Please click to change to the next slide

## Challenges to Doing Research on Organizations

-  Cost of data collection
- Research assistants
- Reproduction costs
- Research assistants, phone interviews
- Coding
- Travel

- Please click to change to the next slide

## Challenges to Doing Research on Organizations

- Funders tend to like large data sets
- Generalizability
- Statistical power
- But: Often can learn more about interesting phenomena through well-designed in-depth case studies
- But: These are expensive and difficult to conduct and analyze

- Please click to change to the next slide

- Relevance:
- Very expensive and difficult to design a true experiment
- Most of the macro-level theories are much better at explaining than prescribing

- Please click to change to the next slide

- Please click to change to the next slide