A literature review of leadership training and a novel conceptual model of leader-member exchange theory for new dentists.

PURPOSE: The purpose of the paper is to describe the current state of leadership and leader-member exchange (LMX) theory in dentistry and develop a novel conceptual model of LMX to guide future research and highlight the importance of enhancing leadership training for new dentists. DESIGN/METHODOLOGY/APPROACH: A literature review exploring leadership in dentistry and LMX in dentistry was completed. The findings were analyzed with framework analysis to develop a novel conceptual model of LMX specific to dentistry. FINDINGS: LMX theory was applied to leadership in dentistry, including a focus on new dentists, senior dentists, other dental team members and the patient. A new conceptual model of the New Dentist LMX Quartet, which is unique and specific to new dentist teams, was developed. RESEARCH LIMITATIONS/IMPLICATIONS: The study identifies the need for research in LMX in dentistry, contributes a new conceptual model for LMX theory and identifies future research. PRACTICAL IMPLICATIONS: Practitioners, policymakers and educators can utilize this information to explore concepts in leadership and improve training and dental practice. ORIGINALITY/VALUE: No other studies specifically exploring LMX in dentistry for new dentists exist. The current literature review and conceptual paper begins the conversation on developing understanding of leadership in dentistry through further research.

The influence of leadership facilitation on relational coordination among primary care team members of accountable care organizations.

BACKGROUND: Teamwork is a central aspect of integrated care delivery and increasingly critical to primary care practices of accountable care organizations. Although the importance of leadership facilitation in implementing organizational change is well documented, less is known about the extent to which strong leadership facilitation can positively influence relational coordination among primary care team members. PURPOSE: The aim of this study was to examine the association of leadership facilitation of change and relational coordination among primary care teams of accountable care organization-affiliated practices and explore the role of team participation and solidarity culture as mediators of the relationship between leadership facilitation and relational coordination among team members. METHODOLOGY/APPROACH: Survey responses of primary care clinicians and staff (n = 764) were analyzed. Multilevel linear regression estimated the relationships among leadership facilitation, team participation, group solidarity, and relational coordination controlling for age, time, occupation, gender, team tenure, and team size. Models included practice site random effects to account for the clustering of respondents within practices. RESULTS: Leadership facilitation (ß = 0.19, p < .001) and team participation (ß = 0.18, p < .001) were positively associated with relational coordination, but solidarity culture was not associated. The association of leadership facilitation and relational coordination was only partially mediated (9%) by team participation. CONCLUSIONS: Leadership facilitation of change is positively associated with relational coordination of primary care team members. The relationship is only partially explained by better team participation, indicating that leadership facilitation has a strong direct effect on relational coordination. Greater solidarity was not associated with better relational coordination and may not contribute to better team task coordination. PRACTICE IMPLICATIONS: Leadership facilitation of change may have a positive and direct impact on high relational coordination among primary care team members.

Improving Care Transitions Management: Examining the Role of Accountable Care Organization Participation and Expanded Electronic Health Record Functionality.

OBJECTIVE: Examine the extent to which physician organization participation in an accountable care organization (ACO) and electronic health record (EHR) functionality are associated with greater adoption of care transition management (CTM) processes. DATA SOURCES/STUDY SETTING: A total of 1,398 physician organizations from the third National Study of Physician Organization survey (NSPO3), a nationally representative sample of medical practices in the United States (January 2012-May 2013). STUDY DESIGN: We used data from the third National Study of Physician Organization survey (NSPO3) to assess medical practice characteristics, including CTM processes, ACO participation, EHR functionality, practice type, organization size, ownership, public reporting, and pay-for-performance participation. DATA COLLECTION/EXTRACTION METHODS: Multivariate linear regression models estimated the extent to which ACO participation and EHR functionality were associated with greater CTM capabilities, controlling for practice size, ownership, public reporting, and pay-for-performance participation. PRINCIPAL FINDINGS: Approximately half (52.4 percent) of medical practices had a formal program for managing care transitions in place. In adjusted analyses, ACO participation (p < .001) and EHR functionality (p < .001) were independently associated with greater use of CTM processes among medical practices. CONCLUSIONS: The growth of ACOs and similar provider risk-bearing arrangements across the country may improve the management of care transitions by physician organizations.

Microsystems in health care: Part 8. Developing people and improving work life: what front-line staff told us.

BACKGROUND: The articles in the Microsystems in Health Care series have focused on the success characteristics of high-performing clinical microsystems. Realization is growing about the importance of attracting, selecting, developing, and engaging staff. By optimizing the work of all staff members and by promoting a culture where everyone matters, the microsystem can attain levels of performance not previously experienced. CASE STUDY: At Massachusetts General Hospital Downtown Associates (Boston), a primary care practice, the human resource processes are specified and predictable, from a candidate's initial contact through each staff member's orientation, performance management, and professional development. Early on, the new employee receives materials about the practice, including a practice overview, his or her typical responsibilities, the performance evaluation program, and continuous quality improvement. Ongoing training and education are supported with skill labs, special education nights, and cross-training. The performance evaluation program, used to evaluate the performance of all employees, is completed during the 90-day orientation and training, quarterly for one year, and annually. CONCLUSION: Some health care settings enjoy high morale, high quality, and high productivity, but all too often this is not the case. The case study offers an example of a microsystem that has motivated its staff and created a positive and dynamic workplace.

Microsystems in health care: Part 5. How leaders are leading.

BACKGROUND: Leading and leadership by formal and informal leaders goes on at all levels of microsystems--the essential building blocks of all health systems--and between them. It goes on between microsystems and other levels of the systems in health care. This series on high-performing clinical microsystems is based on interviews and site visits to 20 clinical microsystems in the United States. This fifth article in the series describes how leaders contribute to the performance of those microsystems. ANALYSIS OF INTERVIEWS: Interviews of leaders and staff members offer a rich understanding of the three core processes of leading. Building knowledge requires many behaviors of leaders and has many manifestations as leaders seek to build knowledge about the structure, processes, and patterns of work in their clinical microsystems. Taking action covers many different behaviors--making things happen, executing plans, making good on intentions. It focuses action on the way people are hired and developed and involves the way the work gets done. Reviewing and reflecting provides insight as to how the microsystem's patterns, processes, and structure enable the desired work to get done; what success looks like; and what will be next after that "success" is created. CONCLUSION: The focus on the processes of leading is intended to enable more people to develop into leaders and more people to share the roles of leading.

Microsystems in health care: Part 2. Creating a rich information environment.

BACKGROUND: A rich information environment supports the functioning of the small, functional, frontline units--the microsystems--that provide most health care to most people. Three settings represent case examples of how clinical microsystems use data in everyday practice to provide high-quality and cost-effective care. CASES: At The Spine Center at Dartmouth, Lebanon, New Hampshire, a patient value compass, a one-page health status report, is used to determine if the provided care and services are meeting the patient's needs. In Summit, New Jersey, Overlook Hospital's emergency department (ED) uses uses real-time process monitoring on patient care cycle times, quality and productivity indicator tracking, and patient and customer satisfaction tracking. These data streams create an information pool that is actively used in this ED icrosystem--minute by minute, hourly, daily, weekly, and annually--to analyze performance patterns and spot flaws that require action. The Shock Trauma Intensive Care Unit (STRICU), Intermountain Health Care, Salt Lake City, uses a data system to monitor the "wired" patient remotely and share information at any time in real time. Staff can complete shift reports in 10 minutes. DISCUSSION: Information exchange is the interface that connects staff to patients and staff to staff within the microsystem; microsystem to microsystem; and microsystem to macro-organization.

Microsystems in health care: Part 1. Learning from high-performing front-line clinical units.

BACKGROUND: Clinical microsystems are the small, functional, front-line units that provide most health care to most people. They are the essential building blocks of larger organizations and of the health system. They are the place where patients and providers meet. The quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed. METHODS: A wide net was cast to identify and study a sampling of the best-quality, best-value small clinical units in North America. Twenty microsystems, representing different component parts of the health system, were examined from December 2000 through June 2001, using qualitative methods supplemented by medical record and finance reviews. RESULTS: The study of the 20 high-performing sites generated many best practice ideas (processes and methods) that microsystems use to accomplish their goals. Nine success characteristics were related to high performance: leadership, culture, macro-organizational support of microsystems, patient focus, staff focus, interdependence of care team, information and information technology, process improvement, and performance patterns. These success factors were interrelated and together contributed to the microsystem's ability to provide superior, cost-effective care and at the same time create a positive and attractive working environment. CONCLUSIONS: A seamless, patient-centered, high-quality, safe, and efficient health system cannot be realized without the transformation of the essential building blocks that combine to form the care continuum.