The Effects of Organization Design and Patient Perceptions of Care on Switching Behavior and Reliance on a Health Care System Across Time.

Sustaining ongoing relationships with patients is a strategic, clinically relevant goal of health care systems. This study develops and tests a conceptual model that aims to account for the influence of organization design, perceptions of quality of patient care, and other patient-level factors on the extent to which patients sustain reliance on a health care system. We use a longitudinal survey design and structural equation modeling to predict increases or decreases in patient reliance on the Department of Veterans Affairs health care system across a 4-year period for Veterans with Parkinson's Disease. Our findings show that specialized and integrated clinical practices have a positive association with the quality of patient care. Health care systems may be able to foster long-term relations with patients and improve service quality by allocating resources to form integrated, specialized, disease-specific centers of care designed for patients with chronic illnesses.

How personal and standardized coordination impact implementation of integrated care.

BACKGROUND: Integrating health care across specialized work units has the potential to lower costs and increase quality and access to mental health care. However, a key challenge for healthcare managers is how to develop policies, procedures, and practices that coordinate care across specialized units. The purpose of this study was to identify how organizational factors impacted coordination, and how to facilitate implementation of integrated care. METHODS: Semi-structured interviews were conducted in August 2009 with 30 clinic leaders and 35 frontline staff who were recruited from a convenience sample of 16 primary care and mental health clinics across eight medical centers. Data were drawn from a management evaluation of primary care-mental health integration in the US Department of Veterans Affairs. To protect informant confidentiality, the institutional review board did not allow quotations. RESULTS: Interviews identified antecedents of organizational coordination processes, and highlighted how these antecedents can impact the implementation of integrated care. Overall, implementing new workflow practices were reported to create conflicts with pre-existing standardized coordination processes. Personal coordination (i.e., interpersonal communication processes) between primary care leaders and staff was reported to be effective in overcoming these barriers both by working around standardized coordination barriers and modifying standardized procedures. DISCUSSION: This study identifies challenges to integrated care that might be solved with attention to personal and standardized coordination. A key finding was that personal coordination both between primary care and mental health leaders and between frontline staff is important for resolving barriers related to integrated care implementation. CONCLUSION: Integrated care interventions can involve both new standardized procedures and adjustments to existing procedures. Aligning and integrating procedures between primary care and specialty care requires personal coordination amongst leaders. Interpersonal relationships should be strengthened between staff when personal connections are important for coordinating patient care across clinical settings.

Between and within-site variation in qualitative implementation research.

BACKGROUND: Multisite qualitative studies are challenging in part because decisions regarding within-site and between-site sampling must be made to reduce the complexity of data collection, but these decisions may have serious implications for analyses. There is not yet consensus on how to account for within-site and between-site variations in qualitative perceptions of the organizational context of interventions. The purpose of this study was to analyze variation in perceptions among key informants in order to demonstrate the importance of broad sampling for identifying both within-site and between-site implementation themes. METHODS: Case studies of four sites were compared to identify differences in how Department of Veterans Affairs (VA) medical centers implemented a Primary Care/Mental Health Integration (PC/MHI) intervention. Qualitative analyses focused on between-profession variation in reported referral and implementation processes within and between sites. RESULTS: Key informants identified co-location, the consultation-liaison service, space, access, and referral processes as important topics. Within-site themes revealed the importance of coordination, communication, and collaboration for implementing PC/MHI. The between-site theme indicated that the preexisting structure of mental healthcare influenced how PC/MHI was implemented at each site and that collaboration among both leaders and providers was critical to overcoming structural barriers. CONCLUSIONS: Within- and between-site variation in perceptions among key informants within different professions revealed barriers and facilitators to the implementation not available from a single source. Examples provide insight into implementation barriers for PC/MHI. Multisite implementation studies may benefit from intentionally eliciting and analyzing variation within and between sites. Suggestions for implementation research design are presented.

Grounded theory of barriers and facilitators to mandated implementation of mental health care in the primary care setting.

Objective. There is limited theory regarding the real-world implementation of mental health care in the primary care setting: a type of organizational coordination intervention. The purpose of this study was to develop a theory to conceptualize the potential causes of barriers and facilitators to how local sites responded to this mandated intervention to achieve coordinated mental health care. Methods. Data from 65 primary care and mental health staff interviews across 16 sites were analyzed to identify how coordination was perceived one year after an organizational mandate to provide integrated mental health care in the primary care setting. Results. Standardized referral procedures and communication practices between primary care and mental health were influenced by the organizational factors of resources, training, and work design, as well as provider-experienced organizational boundaries between primary care and mental health, time pressures, and staff participation. Organizational factors and provider experiences were in turn influenced by leadership. Conclusions. Our emergent theory describes how leadership, organizational factors, and provider experiences affect the implementation of a mandated mental health coordination intervention. This framework provides a nuanced understanding of the potential barriers and facilitators to implementing interventions designed to improve coordination between professional groups.

Qualitative analysis of barriers to implementation of supported employment in the Department of Veterans Affairs.

OBJECTIVE: The aim of this qualitative study was to document perceived barriers to supported employment implementation as described by Department of Veterans Affairs (VA) employees. METHODS: Interviews were conducted over two years at six VA medical centers involved in implementing supported employment, an evidence-based practice for helping people with serious mental illness obtain competitive employment. Eighty-four unique semistructured interviews focusing on program development were conducted at the two time points with 110 VA leaders, clinicians, and supported employment staff. A qualitative analysis was performed by using a hybrid of a priori coding categories (focused on organizational transformation) and a data-driven approach to examining perceived barriers to supported employment implementation. RESULTS: Perceived barriers to supported employment implementation were most prominent during the first year of interviews. VA employees across the six sites reported challenges related to employees having paternalistic attitudes about individuals with serious mental illness and being uninformed about the supported employment program. They also reported a lack of organizational structures and leadership to educate providers, facilitate program integration with other teams, and promote the program's value. By the second year, most sites had addressed these challenges. CONCLUSIONS: Paternalistic-uninformed concerns about the ability of persons with serious mental illness to be gainfully employed and a lack of organizational structures and leadership to promote and integrate the supported employment program were common implementation barriers. During implementation, organizations would likely benefit from a formalized educational process of teams involved in the care of supported employment clients and from leadership buy-in to the program and promotion of its significance.

Survey-assessed quality and organizational factors related to quality in Pursuing Perfection hospitals.

BACKGROUND: The goal of the Pursuing Perfection (P2) program was to encourage organizations to push quality improvement to new levels of excellence. As part of an evaluation of P2, we surveyed employees at the 7 participating P2 organizations to (1) assess their perceptions of patient care quality and improvement progress and (2) examine perceived performance on organizational and workgroup characteristics associated with quality. METHODS: Many survey questions were drawn from existing conceptual models and survey instruments. We used factor analysis to create new scales from questions that were not part of established scales. We used correlation coefficients and multivariable models to examine relationships among variables. RESULTS AND CONCLUSIONS: Variables most strongly associated with perceived quality included standardized and simplified care processes resulting in coordinated care and smooth handoffs, a clear sense of organizational direction and clear action plans, and communication with staff about reasons for change and improvement progress made. Of those variables with a strong relationship to quality, ones with relatively low mean ratings included workgroup coordination; sufficient resources and support for improvement; training; and efficient use of people, time, and energy. These are important areas on which management should focus to improve employee ratings of quality.

Patient and organizational factors related to education and support use by Veterans with Parkinson's disease.

Patient education and support services are recognized in the Department of Veterans Affairs (VA) as important to the patient-centered treatment of Parkinson's disease. Indeed, educating patients is one of the missions of the VA's six specialty Parkinson's Disease Research, Education and Clinical Centers (PADRECCs). We compared VA education/support services utilization by whether or not a patient's VA Medical Center (VAMC) contained a PADRECC. Our sample included Parkinson's disease patients from VAMCs with (n = 882) and without (n = 1,448) PADRECCs. Patients completed surveys that asked about demographic/individual characteristics, health status/function, and education/support utilization. Results showed that 15.8% (n = 354) of all patients utilized education/support services. Patients at PADRECC VAMCs were generally healthier and more educated than other VAMC patients. After statistically controlling for these differences, however, being a patient at a PADRECC VAMC site and using only VA providers (as compared to a combination of VA and non-VA providers) were significant predictors of education/support utilization. Further, proportionally more PADRECC VAMC site patients reported higher satisfaction and receiving a broad range of information from different modalities as compared to other VAMC patients. These findings suggest that PADRECC VAMCs are providing educational/support activities consistent with these specialty centers' goals.

Transformational change in health care systems: an organizational model.

BACKGROUND: The Institute of Medicine's 2001 report Crossing the Quality Chasm argued for fundamental redesign of the U.S. health care system. Six years later, many health care organizations have embraced the report's goals, but few have succeeded in making the substantial transformations needed to achieve those aims. PURPOSES: This article offers a model for moving organizations from short-term, isolated performance improvements to sustained, reliable, organization-wide, and evidence-based improvements in patient care. METHODOLOGY: Longitudinal comparative case studies were conducted in 12 health care systems using a mixed-methods evaluation design based on semistructured interviews and document review. Participating health care systems included seven systems funded through the Robert Wood Johnson Foundation's Pursuing Perfection Program and five systems with long-standing commitments to improvement and high-quality care. FINDINGS: Five interactive elements appear critical to successful transformation of patient care: (1) Impetus to transform; (2) Leadership commitment to quality; (3) Improvement initiatives that actively engage staff in meaningful problem solving; (4) Alignment to achieve consistency of organization goals with resource allocation and actions at all levels of the organization; and (5) Integration to bridge traditional intra-organizational boundaries among individual components. These elements drive change by affecting the components of the complex health care organization in which they operate: (1) Mission, vision, and strategies that set its direction and priorities; (2) Culture that reflects its informal values and norms; (3) Operational functions and processes that embody the work done in patient care; and (4) Infrastructure such as information technology and human resources that support the delivery of patient care. Transformation occurs over time with iterative changes being sustained and spread across the organization. PRACTICE IMPLICATIONS: The conceptual model holds promise for guiding health care organizations in their efforts to pursue the Institute of Medicine aims of fundamental system redesign to achieve dramatically improved patient care.