Influences on teleconsultation project utilization rates: the role of dominant logic.

BACKGROUND: This research analyzes teleconsultation from both a mechanistic and complex adaptive system (CAS) dominant logic in order to further understand the influence of dominant logic on utilization rates of teleconsultation projects. In both dominant logics, the objective of teleconsultation projects is to increase access to and quality of healthcare delivery in a cost efficient manner. A mechanistic dominant logic perceives teleconsultation as closely resembling the traditional service delivery model, while a CAS dominant logic focuses on the system's emergent behavior of learning resulting from the relationships and interactions of participating healthcare providers. METHODS: Qualitative case studies of 17 teleconsultation projects that were part of four health sciences center (HSC) based telemedicine networks was utilized. Data were collected at two points in time approximately 10 years apart. Semi-structured interviews of 85 key informants (clinicians, administrators, and IT professionals) involved in teleconsultation projects were the primary data collection method. RESULTS: The findings indicated that the emergent behavior of effective and sustainable teleconsultation projects differed significantly from what was anticipated in a mechanistic dominant logic. Teleconsultation projects whose emergent behavior focused on continuous learning enabled remote site generalists to manage and treat more complex cases and healthcare problems on their own without having to refer to HSC specialists for assistance. In teleconsultation projects that continued to be effectively utilized, participant roles evolved and were expanded. Further, technology requirements for teleconsultation projects whose emergent behavior was learning did not need to be terribly sophisticated. CONCLUSIONS: When a teleconsultation project is designed with a mechanistic dominant logic, it is less likely to be sustained, whereas a teleconsultation project designed with a CAS dominant logic is more likely to be sustained. Consistent with a CAS dominant logic, teleconsultation projects that continued to be utilized involved participants taking on new roles and continuously learning. This continuous learning enabled remote site generalists to better handle the constantly changing nature of the problems faced. A CAS dominant logic provides a theoretical framework which explains why the teleconsultation literature about the role of technology, which is based on a mechanistic dominate logic, does not have adequate explanatory power.

Facilitating telemedicine project sustainability in medically underserved areas: a healthcare provider participant perspective.

BACKGROUND: Very few telemedicine projects in medically underserved areas have been sustained over time. This research furthers understanding of telemedicine service sustainability by examining teleconsultation projects from the perspective of healthcare providers. Drivers influencing healthcare providers' continued participation in teleconsultation projects and how projects can be designed to effectively and efficiently address these drivers is examined. METHODS: Case studies of fourteen teleconsultation projects that were part of two health sciences center (HSC) based telemedicine networks was utilized. Semi-structured interviews of 60 key informants (clinicians, administrators, and IT professionals) involved in teleconsultation projects were the primary data collection method. RESULTS: Two key drivers influenced providers' continued participation. First was severe time constraints. Second was remote site healthcare providers' (RSHCPs) sense of professional isolation. Two design steps to address these were identified. One involved implementing relatively simple technology and process solutions to make participation convenient. The more critical and difficult design step focused on designing teleconsultation projects for collaborative, active learning. This learning empowered participating RSHCPs by leveraging HSC specialists' expertise. CONCLUSIONS: In order to increase sustainability the fundamental purpose of teleconsultation projects needs to be re-conceptualized. Doing so requires HSC specialists and RSHCPs to assume new roles and highlights the importance of trust. By implementing these design steps, healthcare delivery in medically underserved areas can be positively impacted.

Trust and Reflection in Primary Care Practice Redesign.

OBJECTIVE: To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH). DATA SOURCES/STUDY SETTING: Primary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH. STUDY DESIGN: We conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States. Surveys measured seven characteristics of practice relationships (trust, diversity, mindfulness, heedful interrelation, respectful interaction, social/task relatedness, and rich and lean communication) and three organizational attributes (reflection, sensemaking, and learning) of practices. DATA COLLECTION/EXTRACTION METHODS: We surveyed 396 clinicians and practice staff. We performed a multigroup path analysis of the data. Parameter estimates were calculated using a Bayesian estimation method. PRINCIPAL FINDINGS: Trust and reflection were important in explaining the characteristics of practice relationships and their associations with sensemaking and learning. The strongest associations between relationships, sensemaking, and learning were found under conditions of high trust and reflection. The weakest associations were found under conditions of low trust and reflection. CONCLUSIONS: Trust and reflection appear to play a key role in moderating relationships, sensemaking, and learning in practices undergoing practice redesign.

Nighttime clinical encounters: how residents perceive and respond to calls at night.

BACKGROUND: Care fragmentation is common and contributes to communication errors and adverse events. Handoff tools were developed to reduce the potential for these errors. Despite their widespread adoption, there is little information describing their impact on clinical work. Understanding their impact could be helpful in improving handoffs and transitions. OBJECTIVE: To better understand what clinical work is done overnight, the housestaff perceptions of overnight clinical work, and how handoff instruments support this work. DESIGN: Real-time data collection and survey. PARTICIPANTS: Internal medicine resident physicians. MAIN MEASURES: Data collection measured information related to nighttime clinical encounters, including the information sources and actions taken. Surveys assessed resident perceptions toward care transitions. KEY RESULTS: Of 299 encounters, 289 contained complete data. The tool was used as an information source in 27.7% of encounters, whereas the information source was either the nurse or the chart in 94.4% of encounters. Many encounters resulted in a new order for a medication, whereas 3.8% resulted in documentation. In the survey data, 73.6% residents reported the sign-out procedure was safe. CONCLUSION: These data suggest that a handoff tool is not sufficient to address nighttime clinical issues and suggest that effective care requires more than just the information transfer. It may also reflect that electronic medical records have become a readily available information source at the point of care. Sign-out should support residents' ability to make sense of what is happening and integrate care of day and night teams, rather than solely transfer information.

Health care huddles: managing complexity to achieve high reliability.

BACKGROUND: Health care huddles are increasingly employed in a range of formats but theoretical mechanisms underlying huddles remain relatively uncharted. PURPOSE: A complexity science view implies that essential managerial strategies for high-performing health care organizations include meaningful conversations, enhanced relationships, and a learning culture. These three dimensions informed our approach to studying huddles. We explore new theories for how and why huddles have been useful in health care organizations. METHODS: We used a study design incorporating literature review, direct observation, and semistructured interviews. A complexity science framework guided data collection in three health care settings; we also incorporated theories on high-reliability organizations to analyze our observations and interpret huddle participants' perspectives. FINDINGS: We identify theoretical paths that could link huddles to improvement in patient safety outcomes. Huddles create time and space for conversations, enhance relationships, and strengthen a culture of safety. Huddles can be of particular value to health care organizations seeking or sustaining high reliability. PRACTICE IMPLICATIONS: Achieving high reliability, the organizational capacity to deliver what is intended to be delivered every time is difficult in complex systems. Managers have potential to create conditions from which huddle outcomes that support high reliability are more likely to emerge. Huddles support efforts to improve patient safety when they afford opportunities for heedful interactions to take place among individuals caring for patients and embed mindfulness into the organization.

Manifestations and implications of uncertainty for improving healthcare systems: an analysis of observational and interventional studies grounded in complexity science.

BACKGROUND: The application of complexity science to understanding healthcare system improvement highlights the need to consider interdependencies within the system. One important aspect of the interdependencies in healthcare delivery systems is how individuals relate to each other. However, results from our observational and interventional studies focusing on relationships to understand and improve outcomes in a variety of healthcare settings have been inconsistent. We sought to better understand and explain these inconsistencies by analyzing our findings across studies and building new theory. METHODS: We analyzed eight observational and interventional studies in which our author team was involved as the basis of our analysis, using a set theoretical qualitative comparative analytic approach. Over 16 investigative meetings spanning 11 months, we iteratively analyzed our studies, identifying patterns of characteristics that could explain our set of results. Our initial focus on differences in setting did not explain our mixed results. We then turned to differences in patient care activities and tasks being studied and the attributes of the disease being treated. Finally, we examined the interdependence between task and disease. RESULTS: We identified system-level uncertainty as a defining characteristic of complex systems through which we interpreted our results. We identified several characteristics of healthcare tasks and diseases that impact the ways uncertainty is manifest across diverse care delivery activities. These include disease-related uncertainty (pace of evolution of disease and patient control over outcomes) and task-related uncertainty (standardized versus customized, routine versus non-routine, and interdependencies required for task completion). CONCLUSIONS: Uncertainty is an important aspect of clinical systems that must be considered in designing approaches to improve healthcare system function. The uncertainty inherent in tasks and diseases, and how they come together in specific clinical settings, will influence the type of improvement strategies that are most likely to be successful. Process-based efforts appear best-suited for low-uncertainty contexts, while relationship-based approaches may be most effective for high-uncertainty situations.

Improving outcomes of hospitalized patients: the Physician Relationships, Improvising, and Sensemaking intervention protocol.

BACKGROUND: Our goal is to improve the safety and effectiveness of inpatient care. Rather than focus on improving process of care, we focus on the social structure within physician teams. We have developed the Physician Relationships, Improvising, and Sensemaking (PRISm) intervention to improve the way physician teams round, enabling them to better relate, make sense of their patients' conditions, and improvise in uncertain clinical situations. We are currently studying the impact of PRISm on adverse events and complications in hospitalized patients. This manuscript describes the PRISm intervention. METHODS/DESIGN: PRISm is a structured communication tool consisting of three components: daily briefings before rounds; use of the Situation, Task, Intent, Concern, and Calibrate (STICC) framework during rounds as part of the discussion of individual patients; and debriefings after rounds. We are implementing the PRISm intervention on eight inpatient medical and surgical physician teams in the South Texas Veterans Health Care System. We are assessing PRISm impact on the way team members relate to each other, round, and discuss patients through pre- and post-implementation observations and surveys. We are also assessing PRISm impact on complications and adverse events. Finally, we are interviewing physicians regarding their experience using the intervention. DISCUSSION: Our results will allow us to begin to understand the potential impact of interventions designed to improve how providers relate to each other, improvise, and make sense of what is happening as a strategy for improving inpatient care. Our in-depth data collection will enable us to assess how relationships, improvising, and sensemaking influence patient outcomes, potentially through creating shared mental models or enhancing distributed cognition during clinical reasoning. Finally, our results will lay the groundwork for larger implementation studies to improve clinical outcomes through improving how providers, and providers, patients, and caregivers, relate.

Relationships within inpatient physician housestaff teams and their association with hospitalized patient outcomes.

IMPORTANCE: Improving inpatient care delivery has historically focused on improving individual components of the system. Applying the complexity science framework to clinical systems highlights the important role of relationships among providers in influencing system function and clinical outcomes. OBJECTIVE: To understand whether inpatient medical physician teams can be differentiated based on the relationships among team members, and whether these relationships are associated with patient outcomes, including length of stay (LOS), unnecessary length of stay (ULOS), and complication rates. DESIGN: Eleven inpatient medicine teams were observed daily during attending rounds for 2- to 4-week periods from September 2008 through June 2011. Detailed field notes were taken regarding patient care activities, team behaviors, and patient characteristics and outcomes. Behaviors were categorized using the Lanham relationship framework, giving each team a relationship score. We used factor analysis to assess the pattern of relationship characteristics and assessed the association between relationship characteristics and patient outcomes. SETTING: Observations occurred at the Audie L. Murphy Veterans Affairs Hospital and University Hospital in San Antonio, Texas. PARTICIPANTS: Physicians were chosen based on rotation schedules, experience, and time of year. Patients were included based on their admission to the inpatient medicine teams that were being observed. MAIN MEASURES: Relationship scores were based on the presence or absence of 7 relationship characteristics. LOS, ULOS, and complication rates were assessed based on team discussions and chart review. The association between relationships and outcomes was assessed using the Kruskal-Wallis rank sum test. RESULTS: We observed 11 teams over 352.9 hours, observing 1941 discussions of 576 individual patients. Teams exhibited a range of 0 to 7 relationship characteristics. Relationship scores were significantly associated with complication rates, and presence of trust and mindfulness among teams was significantly associated with ULOS and complication rates. CONCLUSIONS: Our findings are an important step in understanding the impact of relationships on the outcomes of hospitalized medical patients. This understanding could expand the scope of interventions to improve hospital care to include not only process improvement but also relationships among providers.

Local interaction strategies and capacity for better care in nursing homes: a multiple case study.

BACKGROUND: To describe relationship patterns and management practices in nursing homes (NHs) that facilitate or pose barriers to better outcomes for residents and staff. METHODS: We conducted comparative, multiple-case studies in selected NHs (N = 4). Data were collected over six months from managers and staff (N = 406), using direct observations, interviews, and document reviews. Manifest content analysis was used to identify and explore patterns within and between cases. RESULTS: Participants described interaction strategies that they explained could either degrade or enhance their capacity to achieve better outcomes for residents; people in all job categories used these 'local interaction strategies'. We categorized these two sets of local interaction strategies as the 'common pattern' and the 'positive pattern' and summarize the results in two models of local interaction. CONCLUSIONS: The findings suggest the hypothesis that when staff members in NHs use the set of positive local interaction strategies, they promote inter-connections, information exchange, and diversity of cognitive schema in problem solving that, in turn, create the capacity for delivering better resident care. We propose that these positive local interaction strategies are a critical driver of care quality in NHs. Our hypothesis implies that, while staffing levels and skill mix are important factors for care quality, improvement would be difficult to achieve if staff members are not engaged with each other in these ways.

Understanding differences in electronic health record (EHR) use: linking individual physicians' perceptions of uncertainty and EHR use patterns in ambulatory care.

OBJECTIVE: Electronic health records (EHR) hold great promise for managing patient information in ways that improve healthcare delivery. Physicians differ, however, in their use of this health information technology (IT), and these differences are not well understood. The authors study the differences in individual physicians' EHR use patterns and identify perceptions of uncertainty as an important new variable in understanding EHR use. DESIGN: Qualitative study using semi-structured interviews and direct observation of physicians (n=28) working in a multispecialty outpatient care organization. MEASUREMENTS: We identified physicians' perceptions of uncertainty as an important variable in understanding differences in EHR use patterns. Drawing on theories from the medical and organizational literatures, we identified three categories of perceptions of uncertainty: reduction, absorption, and hybrid. We used an existing model of EHR use to categorize physician EHR use patterns as high, medium, and low based on degree of feature use, level of EHR-enabled communication, and frequency that EHR use patterns change. RESULTS: Physicians' perceptions of uncertainty were distinctly associated with their EHR use patterns. Uncertainty reductionists tended to exhibit high levels of EHR use, uncertainty absorbers tended to exhibit low levels of EHR use, and physicians demonstrating both perspectives of uncertainty (hybrids) tended to exhibit medium levels of EHR use. CONCLUSIONS: We find evidence linking physicians' perceptions of uncertainty with EHR use patterns. Study findings have implications for health IT research, practice, and policy, particularly in terms of impacting health IT design and implementation efforts in ways that consider differences in physicians' perceptions of uncertainty.

Participation in decision making as a property of complex adaptive systems: developing and testing a measure.

Objectives. To (1) describe participation in decision-making as a systems-level property of complex adaptive systems and (2) present empirical evidence of reliability and validity of a corresponding measure. Method. Study 1 was a mail survey of a single respondent (administrators or directors of nursing) in each of 197 nursing homes. Study 2 was a field study using random, proportionally stratified sampling procedure that included 195 organizations with 3,968 respondents. Analysis. In Study 1, we analyzed the data to reduce the number of scale items and establish initial reliability and validity. In Study 2, we strengthened the psychometric test using a large sample. Results. Results demonstrated validity and reliability of the participation in decision-making instrument (PDMI) while measuring participation of workers in two distinct job categories (RNs and CNAs). We established reliability at the organizational level aggregated items scores. We established validity of the multidimensional properties using convergent and discriminant validity and confirmatory factor analysis. Conclusions. Participation in decision making, when modeled as a systems-level property of organization, has multiple dimensions and is more complex than is being traditionally measured. Managers can use this model to form decision teams that maximize the depth and breadth of expertise needed and to foster connection among them.

Effects of facilitated team meetings and learning collaboratives on colorectal cancer screening rates in primary care practices: a cluster randomized trial.

PURPOSE: The purpose of this study was to evaluate a primary care practice-based quality improvement (QI) intervention aimed at improving colorectal cancer screening rates. METHODS: The Supporting Colorectal Cancer Outcomes through Participatory Enhancements (SCOPE) study was a cluster randomized trial of New Jersey primary care practices. On-site facilitation and learning collaboratives were used to engage multiple stakeholders throughout the change process to identify and implement strategies to enhance colorectal cancer screening. Practices were analyzed using quantitative (medical records, surveys) and qualitative data (observations, interviews, and audio recordings) at baseline and a 12-month follow-up. RESULTS: Comparing intervention and control arms of the 23 participating practices did not yield statistically significant improvements in patients' colorectal cancer screening rates. Qualitative analyses provide insights into practices' QI implementation, including associations between how well leaders fostered team development and the extent to which team members felt psychologically safe. Successful QI implementation did not always translate into improved screening rates. CONCLUSIONS: Although single-target, incremental QI interventions can be effective, practice transformation requires enhanced organizational learning and change capacities. The SCOPE model of QI may not be an optimal strategy if short-term guideline concordant numerical gains are the goal. Advancing the knowledge base of QI interventions requires future reports to address how and why QI interventions work rather than simply measuring whether they work.

The role of improvising in patient care.

BACKGROUND: Uncertainty is inherent in health care systems. This uncertainty is related to the complexity of the system itself, as well as the potentially unpredictable trajectory of each patient's disease. One implication of uncertainty is that patient outcomes may be dependent on providers' ability to perform effectively in uncertain situations. Improvising is a critical activity that helps physicians act when the course of action is unclear or not routine. PURPOSES: The objective of this study was to describe the phenomenon and role of improvising in health care settings. METHODOLOGY/APPROACH: We observed 7 inpatient physician teams, analyzed a written case, and interviewed 7 physicians across specialties. We identified examples and themes related to improvising in each of these data sources. FINDINGS: We observed improvising in 2 of the 7 observed inpatient teams. We also identified improvising in the written case. Examples of improvising in health care were reported in 6 of the 7 physician interviews. In these examples, improvising was manifested in different ways, ranging from specific treatment regimens to interactions with patients and their families. However, the description of social interactions leading to a change from the usual course of action was a common theme. PRACTICE IMPLICATIONS: Improvising frequently occurs in health care, enabling physicians to adjust to the inherent uncertainty of patient care activities. Improvising is contingent on a foundation of medical knowledge from which providers can act in creative, novel ways. In addition, improvising is a social activity requiring a supportive relationship infrastructure. Enabling improvising may be an important approach for improving patient outcomes. Improving relationships will be an important component of these strategies.

Health care organizations as complex systems: new perspectives on design and management.

PURPOSE: We discuss the impact of complexity science on the design and management of health care organizations over the past decade. We provide an overview of complexity science issues and their impact on thinking about health care systems, particularly with the rising importance of information systems. We also present a complexity science perspective on current issues in today's health care organizations and suggest ways that this perspective might help in approaching these issues. APPROACH: We review selected research, focusing on work in which we participated, to identify specific examples of applications of complexity science. We then take a look at information systems in health care organizations from a complexity viewpoint. FINDINGS: Complexity science is a fundamentally different way of understanding nature and has influenced the thinking of scholars and practitioners as they have attempted to understand health care organizations. Many scholars study health care organizations as complex adaptive systems and through this perspective develop new management strategies. Most important, perhaps, is the understanding that attention to relationships and interdependencies is critical for developing effective management strategies. RESEARCH AND PRACTICE IMPLICATIONS: Increased understanding of complexity science can enhance the ability of researchers and practitioners to develop new ways of understanding and improving health care organizations. ORIGINALITY/VALUE: This analysis opens new vistas for scholars and practitioners attempting to understand health care organizations as complex adaptive systems. The analysis holds value for those already familiar with this approach as well as those who may not be as familiar.

Exploring interpersonal behavior and team sensemaking during health information technology implementation.

PURPOSE: We examine how interpersonal behavior and social interaction influence team sensemaking and subsequent team actions during a hospital-based health information technology (HIT) implementation project. DESIGN/METHODOLOGY/APPROACH: Over the course of 18 months, we directly observed the interpersonal interactions of HIT implementation teams using a sensemaking lens. FINDINGS: We identified three voice-promoting strategies enacted by team leaders that fostered team member voice and sensemaking; communicating a vision; connecting goals to team member values; and seeking team member input. However, infrequent leader expressions of anger quickly undermined team sensemaking, halting dialog essential to problem solving. By seeking team member opinions, team leaders overcame the negative effects of anger. PRACTICAL IMPLICATIONS: Leaders must enact voice-promoting behaviors and use them throughout a team's engagement. Further, training teams in how to use conflict to achieve greater innovation may improve sensemaking essential to project risk mitigation. SOCIAL IMPLICATIONS: Health care work processes are complex; teams involved in implementing improvements must be prepared to deal with conflicting, contentious issues, which will arise during change. Therefore, team conflict training may be essential to sustaining sensemaking. RESEARCH IMPLICATIONS: Future research should seek to identify team interactions that foster sensemaking, especially when topics are difficult or unwelcome, then determine the association between staff sensemaking and the impact on HIT implementation outcomes. VALUE/ORIGINALITY: We are among the first to focus on project teams tasked with HIT implementation. This research extends our understanding of how leaders' behaviors might facilitate or impeded speaking up among project teams in health care settings.

Small primary care practices face four hurdles--including a physician-centric mind-set--in becoming medical homes.

Transforming small independent practices to patient-centered medical homes is widely believed to be a critical step in reforming the US health care system. Our team has conducted research on improving primary care practices for more than fifteen years. We have found four characteristics of small primary care practices that seriously inhibit their ability to make the transformation to this new care model. We found that small practices were extremely physician-centric, lacked meaningful communication among physicians, were dominated by authoritarian leadership behavior, and were underserved by midlevel clinicians who had been cast into unimaginative roles. Our analysis suggests that in addition to payment reform, a shift in the mind-set of primary care physicians is needed. Unless primary care physicians can adopt new mental models and think in new ways about themselves and their practices, it will be very difficult for them and their practices to create innovative care teams, become learning organizations, and act as good citizens within the health care neighborhood.

CONNECT for quality: protocol of a cluster randomized controlled trial to improve fall prevention in nursing homes.

BACKGROUND: Quality improvement (QI) programs focused on mastery of content by individual staff members are the current standard to improve resident outcomes in nursing homes. However, complexity science suggests that learning is a social process that occurs within the context of relationships and interactions among individuals. Thus, QI programs will not result in optimal changes in staff behavior unless the context for social learning is present. Accordingly, we developed CONNECT, an intervention to foster systematic use of management practices, which we propose will enhance effectiveness of a nursing home Falls QI program by strengthening the staff-to-staff interactions necessary for clinical problem-solving about complex problems such as falls. The study aims are to compare the impact of the CONNECT intervention, plus a falls reduction QI intervention (CONNECT + FALLS), to the falls reduction QI intervention alone (FALLS), on fall-related process measures, fall rates, and staff interaction measures. METHODS/DESIGN: Sixteen nursing homes will be randomized to one of two study arms, CONNECT + FALLS or FALLS alone. Subjects (staff and residents) are clustered within nursing homes because the intervention addresses social processes and thus must be delivered within the social context, rather than to individuals. Nursing homes randomized to CONNECT + FALLS will receive three months of CONNECT first, followed by three months of FALLS. Nursing homes randomized to FALLS alone receive three months of FALLs QI and are offered CONNECT after data collection is completed. Complexity science measures, which reflect staff perceptions of communication, safety climate, and care quality, will be collected from staff at baseline, three months after, and six months after baseline to evaluate immediate and sustained impacts. FALLS measures including quality indicators (process measures) and fall rates will be collected for the six months prior to baseline and the six months after the end of the intervention. Analysis will use a three-level mixed model. DISCUSSION: By focusing on improving local interactions, CONNECT is expected to maximize staff's ability to implement content learned in a falls QI program and integrate it into knowledge and action. Our previous pilot work shows that CONNECT is feasible, acceptable and appropriate. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00636675.

Same organization, same electronic health records (EHRs) system, different use: exploring the linkage between practice member communication patterns and EHR use patterns in an ambulatory care setting.

OBJECTIVE: Despite efforts made by ambulatory care organizations to standardize the use of electronic health records (EHRs), practices often incorporate these systems into their work differently from each other. One potential factor contributing to these differences is within-practice communication patterns. The authors explore the linkage between within-practice communication patterns and practice-level EHR use patterns. DESIGN: Qualitative study of six practices operating within the same multi-specialty ambulatory care organization using the same EHR system. Semistructured interviews and direct observation were conducted with all physicians, nurses, medical assistants, practice managers, and non-clinical staff from each practice. MEASUREMENTS: An existing model of practice relationships was used to analyze communication patterns within the practices. Practice-level EHR use was defined and analyzed as the ways in which a practice uses an EHR as a collective or a group-including the degree of feature use, level of EHR-enabled communication, and frequency that EHR use changes in a practice. Interview and observation data were analyzed for themes. Based on these themes, within-practice communication patterns were categorized as fragmented or cohesive, and practice-level EHR use patterns were categorized as heterogeneous or homogeneous. Practices where EHR use was uniformly high across all users were further categorized as having standardized EHR use. Communication patterns and EHR use patterns were compared across the six practices. RESULTS: Within-practice communication patterns were associated with practice-level EHR use patterns. In practices where communication patterns were fragmented, EHR use was heterogeneous. In practices where communication patterns were cohesive, EHR use was homogeneous. Additional analysis revealed that practices that had achieved standardized EHR use (uniformly high EHR use across all users) exhibited high levels of mindfulness and respectful interaction, whereas practices that were furthest from achieving standardized EHR use exhibited low levels of mindfulness and respectful interaction. CONCLUSION: Within-practice communication patterns provide a unique perspective for exploring the issue of standardization in EHR use. A major fallacy of setting homogeneous EHR use as the goal for practice-level EHR use is that practices with uniformly low EHR use could be considered successful. Achieving uniformly high EHR use across all users in a practice is more consistent with the goals of current EHR adoption and use efforts. It was found that some communication patterns among practice members may enable more standardized EHR use than others. Understanding the linkage between communication patterns and EHR use can inform understanding of the human element in EHR use and may provide key lessons for the implementation of EHRs and other health information technologies.

Reciprocal learning and chronic care model implementation in primary care: results from a new scale of learning in primary care.

BACKGROUND: Efforts to improve the care of patients with chronic disease in primary care settings have been mixed. Application of a complex adaptive systems framework suggests that this may be because implementation efforts often focus on education or decision support of individual providers, and not on the dynamic system as a whole. We believe that learning among clinic group members is a particularly important attribute of a primary care clinic that has not yet been well-studied in the health care literature, but may be related to the ability of primary care practices to improve the care they deliver.To better understand learning in primary care settings by developing a scale of learning in primary care clinics based on the literature related to learning across disciplines, and to examine the association between scale responses and chronic care model implementation as measured by the Assessment of Chronic Illness Care (ACIC) scale. METHODS: Development of a scale of learning in primary care setting and administration of the learning and ACIC scales to primary care clinic members as part of the baseline assessment in the ABC Intervention Study. All clinic clinicians and staff in forty small primary care clinics in South Texas participated in the survey. RESULTS: We developed a twenty-two item learning scale, and identified a five-item subscale measuring the construct of reciprocal learning (Cronbach alpha 0.79). Reciprocal learning was significantly associated with ACIC total and sub-scale scores, even after adjustment for clustering effects. CONCLUSIONS: Reciprocal learning appears to be an important attribute of learning in primary care clinics, and its presence relates to the degree of chronic care model implementation. Interventions to improve reciprocal learning among clinic members may lead to improved care of patients with chronic disease and may be relevant to improving overall clinic performance.

Hospital boards and hospital strategic focus: the impact of board involvement in strategic decision making.

BACKGROUND: Despite pressures to change the role of hospital boards, hospitals have made few changes in board composition or director selection criteria. Hospital boards have often continued to operate in their traditional roles as either "monitors" or "advisors." More attention to the direct involvement of hospital boards in the strategic decision-making process of the organizations they serve, the timing and circumstances under which board involvement occurs, and the board composition that enhances their abilities to participate fully is needed. PURPOSES: We investigated the relationship between broader expertise among hospital board members, board involvement in the stages of strategic decision making, and the hospital's strategic focus. METHODOLOGY/APPROACH: We surveyed top management team members of 72 nonacademic hospitals to explore the participation of critical stakeholder groups such as the board of directors in the strategic decision-making process. We used hierarchical regression analysis to explore our hypotheses that there is a relationship between both the nature and involvement of the board and the hospital's strategic orientation. FINDINGS: Hospitals with broader expertise on their boards reported an external focus. For some of their externally-oriented goals, hospitals also reported that their boards were involved earlier in the stages of decision making. PRACTICE IMPLICATIONS: In light of the complex and dynamic environment of hospitals today, those charged with developing hospital boards should match the variety in the external issues that the hospital faces with more variety in board makeup. By developing a board with greater breadth of expertise, the hospital responds to its complex environment by absorbing that complexity, enabling a greater potential for sensemaking and learning. Rather than acting only as monitors and advisors, boards impact their hospitals' strategic focus through their participation in the strategic decision-making process.