Testing the Integrative Quality Care Assessment Tool (INQUAT).

PURPOSE: Identifying the factors that contribute or hinder the provision of good quality care within healthcare institutions, from the managers' perspective, is important for the success of quality improvement initiatives. The purpose of this paper is to test the Integrative Quality Care Assessment Tool (INQUAT) that was previously developed with a sample of healthcare managers in the USA. DESIGN/METHODOLOGY/APPROACH: Written narratives of 69 good and poor quality care episodes were collected from 37 managers in Italy. A quantitative content analysis was conducted using the INQUAT coding scheme, to compare the results of the US-based study to the new Italian sample. FINDINGS: The core frame of the INQUAT was replicated and the meta-categories showed similar distributions compared to the US data. Structure (i.e. organizational, staff and facility resources) covered 8 percent of all the coded units related to quality aspects; context (i.e. clinical factors and patient factors) 10 percent; process (i.e. communication, professional diligence, timeliness, errors and continuity of care) 49 percent; and outcome (i.e. process- and short-term outcomes) 32 percent. However, compared to the US results, Italian managers attributed more importance to different categories' subcomponents, possibly due to the specificity of each sample. For example, professional diligence, errors and continuity of care acquired more weight, to the detriment of communication. Furthermore, the data showed that process subcomponents were associated to perceived quality more than outcomes. RESEARCH LIMITATIONS/IMPLICATIONS: The major limitation of this investigation was the small sample size. Further studies are needed to test the reliability and validity of the INQUAT. ORIGINALITY/VALUE: The INQUAT is proposed as a tool to systematically conduct in depth analyses of successful and unsuccessful healthcare events, allowing to better understand the factors that contribute to good quality and to identify specific areas that may need to be targeted in quality improvement initiatives.

Determinants of good and poor quality as perceived by US health care managers.

Purpose The scientific literature evidences that the quality of care must be improved. However, little research has focused on investigating how health care managers - who are responsible for the implementation of quality interventions - define good and poor quality. The purpose of this paper is to develop an empirically informed taxonomy of quality care as perceived by US managers - named the Integrative Quality Care Assessment Tool (INQUAT) - that is grounded in Donabedian's structure, process and outcome model. Design/methodology/approach A revised version of the critical incident technique was used to collect 135 written narratives of good and poor quality care from 74 health care managers in the USA. The episodes were thematically analyzed. Findings In total, 804 units were coded under the 135 written narratives of care. They were grouped under structure (9 percent, n=69), including organizational, staff and facility resources; process (52 percent, n=419), entailing communication, professional diligence, timeliness, errors, and continuity of care; outcomes (32 percent, n=257), embedding process- and short-term outcomes; and context (7 percent, n=59), involving clinical and patient factors. Process-related categories tended to be described in relation to good quality (65 percent), while structure-related categories tended to be associated with poor quality (67 percent). Furthermore, the data suggested that managers did not consider their actions as important factors influencing quality, but rather tended to attribute the responsibility for quality care to front-line practitioners. Originality/value The INQUAT provides a theoretically grounded, evidence-based framework to guide health care managers in the assessment of all the components involved with the quality of care within their institutions.

Health status and health systems financing in the MENA region: roadmap to universal health coverage.

BACKGROUND: Since the declaration of the Millennium Development Goals (MDGs) in 1990, many countries of the Middle East and North Africa (MENA) region made some improvements in maternal and child health and in tackling communicable diseases. The transition to the global agenda of Sustainable Development Goals brings new opportunities for countries to move forward toward achieving progress for better health, well-being, and universal health coverage. This study provides a profile of health status and health financing approaches in the MENA region and their implications on universal health coverage. METHODS: Time-series data on socioeconomics, health expenditures, and health outcomes were extracted from databases and reports of the World Health Organization, the World Bank and the United Nations Development Program and analyzed using Stata 12 statistical software. Countries were grouped according to the World Bank income categories. Descriptive statistics, tables and charts were used to analyze temporal changes and compare the key variables with global averages. RESULTS: Non-communicable diseases (NCDs) and injuries account for more than three quarters of the disability-adjusted life years in all but two lower middle-income countries (Sudan and Yemen). Prevalence of risk factors (raised blood glucose, raised blood pressure, obesity and smoking) is higher than global averages and counterparts by income group. Total health expenditure (THE) per capita in most of the countries falls short of global averages for countries under similar income category. Furthermore, growth rate of THE per capita has not kept pace with the growth rate of GDP per capita. Out-of-pocket spending (OOPS) in all but the high-income countries in the group exceeds the threshold for catastrophic spending implying that there is a high risk of households getting poorer as a result of paying for health care. CONCLUSION: The alarmingly high prevalence of NCDs and injuries and associated risk factors, health spending falling short of the GDP and GDP growth rate, and high OOPS pose serious challenges for universal health coverage. Using multi-sector interventions, countries should develop and implement evidence-informed health system financing roadmaps to address these obstacles and move forward toward universal health coverage.

Hospital Systems, Convenient Care Strategies, and Healthcare Reform.

Retail clinics (RCs) and urgent care centers (UCCs) are convenient care models that emerged on the healthcare scene in the past 10 to 15 years. Characterized as disruptive innovations, these models of healthcare delivery seem to follow a slightly different path from each other. Hospital systems, the very organizations that were originally threatened by convenient care models, are developing them and partnering with existing models. We posit that legislative changes such as the Affordable Care Act created challenges for hospital systems that accelerated their adoption of these models. In this study, we analyze 117 hospital systems in six states and report on their convenient care strategies. Our data suggest that UCCs are more prevalent than RCs among hospital systems, and that large and unexplained state-by-state variations exist in the adoption of these strategies. We also postulate about the future role of hospital systems in leading these innovations.

Enhancing physician engagement: an international perspective.

The purpose of this article is to provide specific recommendations to enhance physician engagement in health care organizations. It summarizes the evidence on physician engagement, drawing on peer-reviewed articles and reports from the gray literature, and suggests an integrative framework to help health care managers better understand and improve physician engagement. While we examine some other international examples and experiences, we mainly focus on physician engagement in Canada, the United States, and the United Kingdom. Physician engagement can be conceptualized as an ongoing two-way social process in which both the individual and organizational/cultural components are considered. Building on several frameworks and examples, we propose a new integrative framework for enhancing physician engagement in health care organizations. We suggest that in order to enhance physician engagement, organizations should focus on the following strategies: developing clear and efficient communication channels with physicians; building trust, understanding, and respect with physicians; and identifying and developing physician leaders. We propose that the time is now for health care managers to set aside traditional differences and historical conflicts and to engage their physicians for the betterment of their organizations.

The evolution of retail clinics in the United States, 2006-2012.

In the recent decade, retail clinics have emerged to offer routine preventative and acute care services by nonphysician providers, with predictable wait times, more convenient venues, and posted prices. This article evaluates the evolution of retail clinics between 2006 and 2012 and examines the yearly openings and closings of clinics by location, owner, operator, and other important characteristics. The Merchant Medicine database was used. It is the only database of its kind that includes every retail clinic opening and closing since 2006. The data are collected on a monthly basis through operator self-report, telephone calls to operators, and monitoring of operator Web sites and articles in local newspapers. A growth period of 2006 through 2008 can be attributed to what was referred to at the time as a "land grab," in which competing operators sought to be the first to open in new markets. In 2008, with the start of the general economic recession, numerous clinics shut down during the slow spring and summer months and others closed altogether. The industry remains dominated by large retail pharmacy operators, and the involvement of hospital systems in retail clinic ownership is a recent and interesting phenomenon. An important question to address is the following: Will retail clinics remain as just a convenient way for busy insured patients to seek care afterhours and on weekends, or can they have a more significant impact in a primary care system on the brink of collapse?

How satisfied are hospital systems with their ownership of retail clinics?

Retail clinics--while innovative--can no longer be considered a new model of healthcare delivery, as an increasing number of hospitals and health systems now own them. The purpose of this article is to explore the extent to which hospital systems are satisfied with their ownership of retail clinics. In terms of operational challenges, respondents to our survey, administered to representatives from 19 health systems, were relatively satisfied with clinic staffing and their relationship with the retailers regarding lease terms, store locations, and shopper demographics. They expressed mostly neutral levels of satisfaction with regulations and laws related to retail clinics and low satisfaction with insurance reimbursement and clinics' seasonal patterns. The two areas that received the lowest respondent satisfaction ratings were patient volume and response to marketing initiatives. When asked to share their perceptions of their organization's satisfaction with various strategic aspects of retail clinic ownership, respondents revealed that the clinics were achieving several important strategic goals, such as improved access, increased referrals, defense against competitors, and increased brand exposure. They indicated overall dissatisfaction with profitability and cost-reduction outcomes. We conclude that serious operational challenges and strategic threats must be overcome if retail clinics are to be a successful service line for hospitals and health systems.

Strategic planning processes and financial performance among hospitals in Lebanon.

BACKGROUND: Strategic planning has been presented as a valuable management tool. However, evidence of its deployment in healthcare and its effect on organizational performance is limited in low-income and middle-income countries (LMICs). The study aimed to explore the use of strategic planning processes in Lebanese hospitals and to investigate its association with financial performance. METHODS: The study comprised 79 hospitals and assessed occupancy rate (OR) and revenue-per-bed (RPB) as performance measures. The strategic planning process included six domains: having a plan, plan development, plan implementation, responsibility of planning activities, governing board involvement, and physicians' involvement. RESULTS: Approximately 90% of hospitals have strategic plans that are moderately developed (mean score of 4.9 on a 1-7 scale) and implemented (score of 4.8). In 46% of the hospitals, the CEO has the responsibility for the plan. The level of governing board involvement in the process is moderate to high (score of 5.1), whereas physician involvement is lower (score of 4.1). The OR and RPB amounted to respectively 70% and 59 304 among hospitals with a strategic plan as compared with 62% and 33 564 for those lacking such a plan. No statistical association between having a strategic plan and either of the two measures was detected. However, the findings revealed that among hospitals that had a strategic plan, higher implementation levels were associated with lower OR (p < 0.05). CONCLUSIONS: In an LMIC healthcare environment characterized by resource limitation, complexity, and political and economic volatility, flexibility rather than rigid plans allow organizations to better cope with environmental turbulence.

"Learning" from other industries: lessons and challenges for health care organizations.

Although it is true that health care has several distinguishing characteristics that set it apart, analysts both within and outside the industry point to several similarities with other fields and suggest opportunities for health care to learn from other industries. Applications from other industries have been described in the literature, but the transfer of learning at health care industry level has not been examined. This article investigates health care learning from other industries in the recent decade, focusing on aviation, high-reliability organizations, car manufacturing, telecommunication, car racing, entertainment, and retail; evidence suggests that most innovative practices originate with these fields. The diffusion of innovations from other industries appears to start with a few early adopter organizations (hospitals and health systems) and influential other organizations (The Joint Commission, Institute of Medicine, Agency for Healthcare Research and Quality, or Institute for Healthcare Improvement) pushing for the innovations. Once the trend becomes accepted, consultants and copying behavior seem to contribute to its spread across the industry. An important question to explore is whether the applications in the early adopter organizations are different (in terms of their effectiveness) from those in the rest of the industry. Another intriguing issue is to examine whether other industries learn from health care organizations.

Hospital-affiliated and hospital-owned retail clinics: strategic opportunities and operational challenges.

Retail clinics have experienced an exponential growth in the last few years. While the majority of retail clinics are freestanding, venture-backed companies affiliated with retail hosts, an increasing number of hospital systems have decided to develop their own retail clinics or partner with existing national companies. Using a stakeholder approach, the purpose of this article is to assess the strategic considerations behind these decisions and the operational challenges associated with them and to use the results to develop a questionnaire that can be applied in future research in a national sample of healthcare executives. We conducted eight in-depth interviews with administrative and clinical leaders in seven hospital systems across the United States that have or had a relationship with retail clinics in the last three years. Our findings show that the hospital systems' association with retail clinics involves two main models: an affiliation with retail chains that operate the clinics and ownership of the clinics with an arms-length relationship with the retail chain. Hospital systems are engaging in these relationships for several strategic reasons: to increase market share through enhanced referrals to physician offices and hospitals, to become closer to consumers, and to experiment with nontraditional ways of delivering health care. Operational challenges included physician resistance and skepticism, poor financial performance, people's perception of retail clinics, staffing issues, and the newness of the business model. Six out of eight respondents thought that hospital affiliation with/ownership of retail clinics is a trend that is here to stay, although many provided caveats and stipulations. Further research is needed to provide more evidence about this emerging way of healthcare delivery.

The future of retail clinics: in a volatile health care environment.

Recent estimates put the total number of retail clinics at more than 1000 nationwide. Some forecasts estimate that explosive growth will continue in the future, whereas others suggest that the retail clinic boom might be ending. This article assesses the retail clinic trend and explores its future viability in the volatile health care environment. Eight administrative and clinical leaders in 7 health systems that are affiliated with or own retail clinics were asked specific questions about the future evolution of retail clinics. Respondents offered mixed opinions about the future of retail clinics, and most were skeptical about their growth potential. Some of the respondents believed that health care reform will be supportive of retail clinics, but there was uncertainty about the specific effects of expansion in insurance coverage. Respondents reacted differently to the prospect of retail clinics expanding their scope of practice to include chronic conditions. Some of them welcomed the trend, but the majority was critical of it for various reasons. At this turning point for the health care system, it is not clear whether retail clinics will represent a significant value proposition for the system or whether they are a fad that will soon pass and disappear.

Organizational factors associated with self-management behaviors in diabetes primary care clinics.

PURPOSE: The purpose of this article is to examine the relationship between organizational characteristics as measured by the Chronic Care Model (CCM) and patient self-management behaviors among patients with type 2 diabetes. METHODS: The study design was cross-sectional. The study setting included 20 primary care clinics from South Texas. The sample included approximately 30 consecutive patients that were enrolled from each clinic for a sample of 617 patients. For the data collection procedures, the CCM survey was completed by caregivers in the clinic. Self-management behaviors were obtained from patient exit surveys. For measures, the CCM consisted of 6 structural dimensions: (1) organization support, (2) community linkages, (3) self-management support, (4) decision support system, (5) delivery system design, and (6) clinical information systems. Patient self-management behavior included whether the patient reported always doing all 4 of the following behaviors as they were instructed: (1) checking blood sugars, (2) following diabetes diet, (3) exercising, and (4) taking medications. For data analyses, to account for clustering of patients within clinics, hierarchical logistic regression models were used. RESULTS: Self-management support was positively associated with medication adherence, while decision support system was positively associated with exercise and all 4 self-management behaviors. Surprisingly, community linkages were negatively associated with medication adherence, while clinical information system was negatively associated with diet and all 4 behaviors. A total score, including all dimensions, was positively associated with only exercise. CONCLUSIONS: Health care providers and diabetes educators in primary care clinics should consider how organizational characteristics of the clinic might influence self-management behaviors of patients. The focus should be on better access to evidence-based information at the point of care and self-management needs and activities.

Is patient satisfaction influenced by the intensity of medical resource use by their physicians?

OBJECTIVE: To determine whether patients' satisfaction with their primary care is related to providers' use of medical resources. STUDY DESIGN: Sixty-two practices serving 2805 patients enrolled in BlueCross BlueShield of Minnesota were analyzed using hierarchical regression models. METHODS: Three measures of satisfaction included patient satisfaction with overall healthcare, patient satisfaction with the time spent with a physician or other provider during a visit, and the likelihood that a patient would recommend the clinic to others. RESULTS: Patient satisfaction was found to be primarily a function of patient characteristics and not of practice characteristics. Providers' use of medical resources was not significantly related to patients' overall ratings of healthcare or to patients' willingness to recommend the practice to others. However, the time spent with a physician or other provider was significantly negatively related to patient satisfaction. Physician workload was significantly related to patient satisfaction. CONCLUSIONS: To improve patient satisfaction, practices should focus on reducing physician workload. Valid measures of patient satisfaction must correct for the strong effects of patient characteristics.

Are elements of the chronic care model associated with cardiovascular risk factor control in type 2 diabetes?

BACKGROUND: Control of modifiable risk factors for cardiovascular (CV) disease, the most common cause of morbidity and mortality among people with Type 2 diabetes is dependent on both patient self-care behaviors and the characteristics of the clinic in which care is delivered. The relationship between control of CV risk factors, patient self-care behaviors, and the presence of CCM (Chronic Care Model) components across multiple primary care clinic settings was examined. METHODS: Thirty consecutive patients presenting with Type 2 diabetes were enrolled from each of 20 primary care clinics from across South Texas. Patients were asked about their stage of change for four self-care behaviors: diet, exercise, glucose monitoring, and medication adherence. CV risk factors included the most recent values of glycosolated hemoglobin (A1C), blood pressure, and (low-density lipoprotein) cholesterol. Clinicians in each clinic completed the Assessment of Chronic Illness Care (ACIC) survey, a validated measure of the CCM components. Hierarchical logistic regression models were used. RESULTS: Only 25 (13%) of the 618 patients had good control of all three CV risk factors. Good control of these risk factors was positively associated with community linkages and delivery system design but was inversely associated with clinical information systems. Patients who were in the maintenance stage of change for all four self-care behaviors were more likely to have all three risk factors well controlled. DISCUSSION: Risk factors for CV disease among patients with diabetes are associated with the structure and design of the clinical microsystem where care is delivered. In addition to focusing on clinician knowledge, future interventions should address the clinical microsystem's structure and design to reduce the burden of CV disease among patients with Type 2 diabetes.

Strategic planning processes and hospital financial performance.

Many common management practices in healthcare organizations, including the practice of strategic planning, have not been subject to widespread assessment through empirical research. If management practice is to be evidence-based, evaluations of such common practices need to be undertaken. The purpose of this research is to provide evidence on the extent of strategic planning practices and the association between hospital strategic planning processes and financial performance. In 2006, we surveyed a sample of 138 chief executive officers (CEOs) of hospitals in the state of Texas about strategic planning in their organizations and collected financial information on the hospitals for 2003. Among the sample hospitals, 87 percent reported having a strategic plan, and most reported that they followed a variety of common practices recommended for strategic planning-having a comprehensive plan, involving physicians, involving the board, and implementing the plan. About one-half of the hospitals assigned responsibility for the plan to the CEO. We tested the association between these planning characteristics in 2006 and two measures of financial performance for 2003. Three dimensions of the strategic planning process--having a strategic plan, assigning the CEO responsibility for the plan, and involving the board--are positively associated with earlier financial performance. Further longitudinal studies are needed to evaluate the cause-and-effect relationship between planning and performance.

The role of nursing in bridging the gap between managers and physicians in hospitals.

Tension between hospital managers and physicians is at an all-time high. This article builds on a previous work on the culture of managers and physicians and suggests that nurses can play an instrumental role in bridging the gap between these 2 cultures. Several similarities appear between managers' and nurses' cultures, other similarities can be found between physicians' and nurses' cultures, whereas nurses' culture seems to fall somewhat in the middle of the continuum on some other cultural aspects. Therefore, we suggest that nursing can and should play a crucial role in bridging the gap between the worlds of management and medicine. In a way, nurses can act as "translators," who can explain physicians' views to managers and vice versa. Practically, this will mean a better-defined role for nurses in key hospital committees and task forces, a more active role of the chief nursing officer in the Chief Executive Officer-Chief Medical Officer, and, more importantly, better representation of nurses on hospital boards that already have physician members.

Fads, fashions, and bandwagons in health care strategy.

BACKGROUND: Many observers have alleged that "fads," "fashions," and "bandwagons" (imitation strategies) are prominent feature of the health care organizational strategy landscape. "Imitation behavior" may fulfill symbolic functions such as signaling innovativeness but results in the adoption of strategies that are effective for some organizations but not for many organizations that adopt them. PURPOSES: We seek to identify and recognize the extent of fads, fashions, and bandwagons in health care strategy, understand the rationale for such imitation behavior, and draw implications for practice, education, and research. METHODOLOGY/APPROACH: We examine theoretical arguments for imitation and evidence on imitation strategies in health care organizations, based on literature review, interviews with health care managers in two different metropolitan areas, and a case example of the purchase of medical group practices by hospitals. FINDINGS: Fads, fashions, and bandwagons can be distinguished from strategic responses to regulatory requirements and efficient strategic choices that are the result of systematic analysis. There are substantial theoretical reasons to expect imitation behavior. Imitation strategies can derive from copying the behavior of "exemplar" organizations or from "keeping up" with competitive rivals. Anecdotal and empirical evidence points to a significant amount of imitation behavior in health care strategy. The performance effects of imitation behavior have not been investigated in past research. PRACTICE IMPLICATIONS: The widespread existence of fads and fashions is an argument for evidence-based management. Although it is essential to learn about strategies that have worked for other organizations, managers should carefully take account of the quality of evidence for the strategy and their organizations' distinctive local conditions. Managers should beware of the tendency of individuals and groups to move too readily to the solution stage of problem solving.