Advancing health equity through organizational change: Perspectives from health care leaders.

BACKGROUND: Published literature on health care administration, management, and leadership and its impacts on health systems' programs to address health care inequities is limited, as is information about how organizations integrate health equity in their cultures, missions, and strategic plans. PURPOSE: The aims of this study were to identify the key components necessary for health systems to implement systematic organizational change to promote health equity and to describe approaches organizations have implemented. METHODOLOGY/APPROACH: We conducted an environmental scan to identify central principles for implementing lasting change in health systems and experts working to advance health equity through organizational change. We interviewed 19 experts in health equity and hospital executives in 2020. Using iterative thematic analysis, we identified common themes. RESULTS: Consistent with the literature on organizational change, interviewees described a variety of systematic approaches to change, all of which involve the following core components: (a) committed and engaged leadership; (b) integrated organizational structure; (c) commitment to quality improvement and patient safety; (d) ongoing training and education; (e) effective data collection and analytics; and (f) stakeholder communication, engagement, and collaboration. CONCLUSION AND PRACTICE IMPLICATIONS: There is no "one-size-fits-all" approach to advancing health equity. Decisions about which components require the most attention vary depending on an organization's internal and external environment. Understanding those environments and identifying which levers will be most effective are essential. As provider organizations strive to develop more strategic and systematic approaches to addressing disparities, long-term vision and commitment are necessary to achieve sustainable organizational change.

Large Health Systems' Prevention Guideline Implementation: A Qualitative Study.

INTRODUCTION: Health systems now employ more than half of U.S. physicians. They have the potential to affect primary care through decision support and financial incentives around clinical prevention guidelines. The processes by which they respond to and implement clinical guidelines remain largely unexplored. METHODS: In 2015, the research team conducted and analyzed interviews with quality leaders from eight hospital-based systems and one physician organization which together employ >33,000 physicians and serve >15 million patients. Executives explained organizational processes to adapt, adopt, disseminate, and incentivize adherence to preventive services guidelines. RESULTS: Nearly all have a formal process for reviewing and refining guidelines, developing clinician support, and disseminating the approved guidelines. Internal and external factors like organizational structure, patient demographics, and payer contracts affect the review processes and resulting guideline adaptations. Challenges to guideline uptake include competing demands on clinician time and the absence of accurate and timely patient data in accessible and user-friendly formats. Interviewees reported that engaging clinicians in guideline review is critical to successful implementation. Electronic health record reminders represent the primary tool for guideline dissemination and reinforcement. Interviewees reported widespread use of performance monitoring and feedback to clinicians, with varying levels of success. Most organizations use financial incentives tied to performance for some of their clinicians, although details vary widely depending on network structures and contractual arrangements. CONCLUSIONS: Health systems play a critical intermediary role between guideline-developing organizations and practicing clinicians. Strengthening the adoption of guidelines requires attention to many factors beyond care delivery.

The Impact of Nursing Home Pay-for-Performance on Quality and Medicare Spending: Results from the Nursing Home Value-Based Purchasing Demonstration.

OBJECTIVE: To evaluate the impact of the Nursing Home Value-Based Purchasing demonstration on quality of care and Medicare spending. DATA SOURCES/STUDY SETTING: Administrative and qualitative data from Arizona, New York, and Wisconsin nursing homes over the base-year (2008-2009) and 3-year (2009-2012) demonstration period. STUDY DESIGN: Nursing homes were randomized to the intervention in New York, while the comparison facilities were constructed via propensity score matching in Arizona and Wisconsin. We used a difference-in-difference analysis to compare outcomes across the base-year relative to outcomes in each of the three demonstration years. To provide context and assist with interpretation of results, we also interviewed staff members at participating facilities. PRINCIPAL FINDINGS: Medicare savings were observed in Arizona in the first year only and Wisconsin for the first 2 years; no savings were observed in New York. The demonstration did not systematically impact any of the quality measures. Discussions with nursing home administrators suggested that facilities made few, if any, changes in response to the demonstration, leading us to conclude that the observed savings likely reflected regression to the mean rather than true savings. CONCLUSION: The Federal nursing home pay-for-performance demonstration had little impact on quality or Medicare spending.