Physician e-mail communication, with patients and other providers, is one of the cornerstones of ... more Physician e-mail communication, with patients and other providers, is one of the cornerstones of effective care coordination but varies significantly across physicians. A physician's external environment may contribute to such variations by enabling or constraining a physician's ability to adopt innovations such as health information technology (HIT) that can be used to support e-mail communication. The aim of the study was to examine whether the relationship of the external environment and physician e-mail communication with patients and other providers is mediated by the practice's HIT availability. The data were obtained from the Health Tracking Physician Survey (2008) and the Area Resource File (2008). Cross-sectional multivariable subgroup path analysis was used to investigate the mediating role of HIT availability across 2,850 U.S. physicians. Solo physicians' perceptions about malpractice were associated with 0.97 lower odds (p < .05) of e-mail communication with patients and other providers, as compared to group and hospital practices, even when mediated by HIT availability. Subgroup analyses indicated that different types of practices are responsive to the different dimensions of the external environment. Specifically, solo practitioners were more responsive to the availability of resources in their environment, with per capita income associated with lower likelihood of physician e-mail communication (OR = 0.99, p < .01). In contrast, physicians working in the group practices were more responsive to the complexity of their environment, with a physician's perception of practicing in environments with higher malpractice risks associated with greater information technology availability, which in turn was associated with a greater likelihood of communicating via e-mail with patients (OR = 1.02, p < .05) and other physicians (OR = 1.03, p < .001). The association between physician e-mail communication and the external environment is mediated by the practice's HIT availability. Efforts to improve physician e-mail communication and HIT adoption may need to reflect the varied perceptions of different types of practices.
Communication between patients and providers is a crucial component of effective care coordinatio... more Communication between patients and providers is a crucial component of effective care coordination and is associated with a number of desired patient and provider outcomes. Despite these benefits, physician-patient and physician-physician communication occurs infrequently. The purpose of this study was to examine the relationship between a medical practice's external environment and physician engagement in communication activities. This was a cross-sectional examination of 4,299 U.S. physicians' self-reported engagement in communication activities. Communication was operationalized as physician's time spent on communication with patients and other providers during a typical work day. The explanatory variables were measures of environmental complexity, dynamism, and munificence. Data sources were the Health Tracking Physician Survey, the Area Resource File database, and the Dartmouth Atlas. Binary logistic regression was used to estimate the association between the environmental factors and physician engagement in communication activities. Several environmental factors, including per capita income (odds ratio range, 1.17-1.38), urban location (odds ratio range, 1.08-1.45), fluctuations in Health Maintenance Organization penetration (odds ratio range, 3.47-13.22), poverty (odds ratio range, 0.80-0.97) and population rates (odds ratio range, 1.01-1.02), and the presence of a malpractice crisis (odds ratio range, 0.22-0.43), were significantly associated with communication. Certain aspects of a physician's external environment are associated with different modes of communication with different recipients (patients and providers). This knowledge can be used by health care managers and policy makers who strive to improve communication between different stakeholders within the health care system (e.g., patient and providers).
Background: Evidence-based management assumes that available research evidence is consistent with... more Background: Evidence-based management assumes that available research evidence is consistent with the problems and decision-making conditions faced by those who will utilize this evidence in practice. Purpose: This article attempts to identify how hospital leaders view key determinants of hospital quality and costs, as well as the fundamental ways these leaders ''think'' about solutions to quality and cost issues in their organizations. The objective of this analysis is to better inform the research agenda and approaches pursued by health services research so that this research reflects the ''realities'' of practice in hospitals. Methods: We conducted a series of semistructured interviews with a convenience sample of eight hospital and three health system leaders. Questions focused on current and future challenges facing hospitals as they relate to hospital quality, costs, and efficiency, and potential solutions to those challenges. Findings: Nine major organizational and managerial factors emerged from the interviews, including staffing, evidence-based practice, information technology, data availability and benchmarking, and leadership. Hospital leaders tend to think about these factors systemically and consider process-related factors as the important drivers of cost and quality.
Capacity building is often described as fundamental to the success of health alliances, yet there... more Capacity building is often described as fundamental to the success of health alliances, yet there are few evaluations that provide alliances with clear guidance on the challenges related to capacity building. This article attempts to identify potential challenges of capacity building in multistakeholder health alliances. The study uses a multiple case study design to identify potential challenges and trade-offs associated with capacity building in four community health alliances in the United States. Multiple challenges were found to be common across the four alliances, including specifying appropriate governance structures and decision-making frameworks, aligning stakeholder interests with the vision of the alliance, balancing short-term objectives with long-term goals, and securing resources to sustain the effort without compromising it. These challenges often involved trade-offs and choices that alliances need to prepare for if they are to approach capacity building in a planful rather than a reactive manner.
... 4 Key Takeaways March 2010 Jeffrey A. Alexander, Jon B. Christianson, Larry R. Hearld, Robert... more ... 4 Key Takeaways March 2010 Jeffrey A. Alexander, Jon B. Christianson, Larry R. Hearld, Robert Hurley, Dennis P. Scanlon and Jeff Beich Summary of Key Findings AF4Q alliances must develop the capacity to sustain their efforts over the long term ...
Recent investigations into the activities of nonprofit hospitals have pointed to weak or lax gove... more Recent investigations into the activities of nonprofit hospitals have pointed to weak or lax governance on the part of some of these organizations. As a result of these events, various federal and state initiatives are now either under way or under discussion to strengthen the governance of hospitals and other nonprofit corporations through mandatory board structures and practices. However, despite policy makers' growing interest in these types of governance reforms, there is in fact little empirical evidence to support their contribution to the effectiveness of hospital boards. The purpose of this article is to report the results of a study examining the relationship between the structure and practices of nonprofit hospital boards relative to the hospital's provision of community benefits. Our results point to modest relationships between these sets of variables, suggesting considerable limitations to what federal and state policy makers can accomplish through legislative initiatives to improve the governance of nonprofit hospitals.
Interest in organizational contributions to the delivery of care has risen significantly in recen... more Interest in organizational contributions to the delivery of care has risen significantly in recent years. A challenge facing researchers, practitioners, and policy makers is identifying ways to improve care by improving the organizations that provide this care, given the complexity of health care organizations and the role organizations play in influencing systems of care. This article reviews the literature on the relationship between the structural characteristics and organizational processes of hospitals and quality of care. The review uses Donabedian's structure-process-outcome and level of analysis frameworks to organize the literature. The results of this review indicate that a preponderance of studies are conducted at the hospital level of analysis and are predominantly focused on the organizational structure-quality outcome relationship. The article concludes with recommendations of how health services researchers can expand their research to enhance one's understanding of the relationship between organizational characteristics and quality of care.
This article presents a systematic review of the research methods used to study quality improveme... more This article presents a systematic review of the research methods used to study quality improvement (QI) effectiveness in health care organizations. The review relied on existing literature as well as emergent themes to identify types of QI programs (e.g., data/feedback, information technology, staff education) and quality outcomes (e.g., mortality, morbidity, unnecessary variation). Studies were separated into four categories according to the type of organization in which the QI program was introduced: (a) hospital, (b) nursing home, (c) physician group, and (d) other health care organization. Results of the review indicate that most QI effectiveness research is conducted in hospital settings, is focused on multiple QI interventions, and utilizes process measures as outcomes. The review also yielded substantial variation with respect to the study designs used to examine QI effectiveness. The article concludes with a critique of these designs and suggestions for ways future research could address these shortcomings.
Background: Evidence-based management assumes that available research evidence is consistent with... more Background: Evidence-based management assumes that available research evidence is consistent with the problems and decision-making conditions faced by those who will utilize this evidence in practice. Purpose: This article attempts to identify how hospital leaders view key determinants of hospital quality and costs, as well as the fundamental ways these leaders ''think'' about solutions to quality and cost issues in their organizations. The objective of this analysis is to better inform the research agenda and approaches pursued by health services research so that this research reflects the ''realities'' of practice in hospitals. Methods: We conducted a series of semistructured interviews with a convenience sample of eight hospital and three health system leaders. Questions focused on current and future challenges facing hospitals as they relate to hospital quality, costs, and efficiency, and potential solutions to those challenges. Findings: Nine major organizational and managerial factors emerged from the interviews, including staffing, evidence-based practice, information technology, data availability and benchmarking, and leadership. Hospital leaders tend to think about these factors systemically and consider process-related factors as the important drivers of cost and quality.
Physician e-mail communication, with patients and other providers, is one of the cornerstones of ... more Physician e-mail communication, with patients and other providers, is one of the cornerstones of effective care coordination but varies significantly across physicians. A physician's external environment may contribute to such variations by enabling or constraining a physician's ability to adopt innovations such as health information technology (HIT) that can be used to support e-mail communication. The aim of the study was to examine whether the relationship of the external environment and physician e-mail communication with patients and other providers is mediated by the practice's HIT availability. The data were obtained from the Health Tracking Physician Survey (2008) and the Area Resource File (2008). Cross-sectional multivariable subgroup path analysis was used to investigate the mediating role of HIT availability across 2,850 U.S. physicians. Solo physicians' perceptions about malpractice were associated with 0.97 lower odds (p < .05) of e-mail communication with patients and other providers, as compared to group and hospital practices, even when mediated by HIT availability. Subgroup analyses indicated that different types of practices are responsive to the different dimensions of the external environment. Specifically, solo practitioners were more responsive to the availability of resources in their environment, with per capita income associated with lower likelihood of physician e-mail communication (OR = 0.99, p < .01). In contrast, physicians working in the group practices were more responsive to the complexity of their environment, with a physician's perception of practicing in environments with higher malpractice risks associated with greater information technology availability, which in turn was associated with a greater likelihood of communicating via e-mail with patients (OR = 1.02, p < .05) and other physicians (OR = 1.03, p < .001). The association between physician e-mail communication and the external environment is mediated by the practice's HIT availability. Efforts to improve physician e-mail communication and HIT adoption may need to reflect the varied perceptions of different types of practices.
Communication between patients and providers is a crucial component of effective care coordinatio... more Communication between patients and providers is a crucial component of effective care coordination and is associated with a number of desired patient and provider outcomes. Despite these benefits, physician-patient and physician-physician communication occurs infrequently. The purpose of this study was to examine the relationship between a medical practice's external environment and physician engagement in communication activities. This was a cross-sectional examination of 4,299 U.S. physicians' self-reported engagement in communication activities. Communication was operationalized as physician's time spent on communication with patients and other providers during a typical work day. The explanatory variables were measures of environmental complexity, dynamism, and munificence. Data sources were the Health Tracking Physician Survey, the Area Resource File database, and the Dartmouth Atlas. Binary logistic regression was used to estimate the association between the environmental factors and physician engagement in communication activities. Several environmental factors, including per capita income (odds ratio range, 1.17-1.38), urban location (odds ratio range, 1.08-1.45), fluctuations in Health Maintenance Organization penetration (odds ratio range, 3.47-13.22), poverty (odds ratio range, 0.80-0.97) and population rates (odds ratio range, 1.01-1.02), and the presence of a malpractice crisis (odds ratio range, 0.22-0.43), were significantly associated with communication. Certain aspects of a physician's external environment are associated with different modes of communication with different recipients (patients and providers). This knowledge can be used by health care managers and policy makers who strive to improve communication between different stakeholders within the health care system (e.g., patient and providers).
Background: Evidence-based management assumes that available research evidence is consistent with... more Background: Evidence-based management assumes that available research evidence is consistent with the problems and decision-making conditions faced by those who will utilize this evidence in practice. Purpose: This article attempts to identify how hospital leaders view key determinants of hospital quality and costs, as well as the fundamental ways these leaders ''think'' about solutions to quality and cost issues in their organizations. The objective of this analysis is to better inform the research agenda and approaches pursued by health services research so that this research reflects the ''realities'' of practice in hospitals. Methods: We conducted a series of semistructured interviews with a convenience sample of eight hospital and three health system leaders. Questions focused on current and future challenges facing hospitals as they relate to hospital quality, costs, and efficiency, and potential solutions to those challenges. Findings: Nine major organizational and managerial factors emerged from the interviews, including staffing, evidence-based practice, information technology, data availability and benchmarking, and leadership. Hospital leaders tend to think about these factors systemically and consider process-related factors as the important drivers of cost and quality.
Capacity building is often described as fundamental to the success of health alliances, yet there... more Capacity building is often described as fundamental to the success of health alliances, yet there are few evaluations that provide alliances with clear guidance on the challenges related to capacity building. This article attempts to identify potential challenges of capacity building in multistakeholder health alliances. The study uses a multiple case study design to identify potential challenges and trade-offs associated with capacity building in four community health alliances in the United States. Multiple challenges were found to be common across the four alliances, including specifying appropriate governance structures and decision-making frameworks, aligning stakeholder interests with the vision of the alliance, balancing short-term objectives with long-term goals, and securing resources to sustain the effort without compromising it. These challenges often involved trade-offs and choices that alliances need to prepare for if they are to approach capacity building in a planful rather than a reactive manner.
... 4 Key Takeaways March 2010 Jeffrey A. Alexander, Jon B. Christianson, Larry R. Hearld, Robert... more ... 4 Key Takeaways March 2010 Jeffrey A. Alexander, Jon B. Christianson, Larry R. Hearld, Robert Hurley, Dennis P. Scanlon and Jeff Beich Summary of Key Findings AF4Q alliances must develop the capacity to sustain their efforts over the long term ...
Recent investigations into the activities of nonprofit hospitals have pointed to weak or lax gove... more Recent investigations into the activities of nonprofit hospitals have pointed to weak or lax governance on the part of some of these organizations. As a result of these events, various federal and state initiatives are now either under way or under discussion to strengthen the governance of hospitals and other nonprofit corporations through mandatory board structures and practices. However, despite policy makers' growing interest in these types of governance reforms, there is in fact little empirical evidence to support their contribution to the effectiveness of hospital boards. The purpose of this article is to report the results of a study examining the relationship between the structure and practices of nonprofit hospital boards relative to the hospital's provision of community benefits. Our results point to modest relationships between these sets of variables, suggesting considerable limitations to what federal and state policy makers can accomplish through legislative initiatives to improve the governance of nonprofit hospitals.
Interest in organizational contributions to the delivery of care has risen significantly in recen... more Interest in organizational contributions to the delivery of care has risen significantly in recent years. A challenge facing researchers, practitioners, and policy makers is identifying ways to improve care by improving the organizations that provide this care, given the complexity of health care organizations and the role organizations play in influencing systems of care. This article reviews the literature on the relationship between the structural characteristics and organizational processes of hospitals and quality of care. The review uses Donabedian's structure-process-outcome and level of analysis frameworks to organize the literature. The results of this review indicate that a preponderance of studies are conducted at the hospital level of analysis and are predominantly focused on the organizational structure-quality outcome relationship. The article concludes with recommendations of how health services researchers can expand their research to enhance one's understanding of the relationship between organizational characteristics and quality of care.
This article presents a systematic review of the research methods used to study quality improveme... more This article presents a systematic review of the research methods used to study quality improvement (QI) effectiveness in health care organizations. The review relied on existing literature as well as emergent themes to identify types of QI programs (e.g., data/feedback, information technology, staff education) and quality outcomes (e.g., mortality, morbidity, unnecessary variation). Studies were separated into four categories according to the type of organization in which the QI program was introduced: (a) hospital, (b) nursing home, (c) physician group, and (d) other health care organization. Results of the review indicate that most QI effectiveness research is conducted in hospital settings, is focused on multiple QI interventions, and utilizes process measures as outcomes. The review also yielded substantial variation with respect to the study designs used to examine QI effectiveness. The article concludes with a critique of these designs and suggestions for ways future research could address these shortcomings.
Background: Evidence-based management assumes that available research evidence is consistent with... more Background: Evidence-based management assumes that available research evidence is consistent with the problems and decision-making conditions faced by those who will utilize this evidence in practice. Purpose: This article attempts to identify how hospital leaders view key determinants of hospital quality and costs, as well as the fundamental ways these leaders ''think'' about solutions to quality and cost issues in their organizations. The objective of this analysis is to better inform the research agenda and approaches pursued by health services research so that this research reflects the ''realities'' of practice in hospitals. Methods: We conducted a series of semistructured interviews with a convenience sample of eight hospital and three health system leaders. Questions focused on current and future challenges facing hospitals as they relate to hospital quality, costs, and efficiency, and potential solutions to those challenges. Findings: Nine major organizational and managerial factors emerged from the interviews, including staffing, evidence-based practice, information technology, data availability and benchmarking, and leadership. Hospital leaders tend to think about these factors systemically and consider process-related factors as the important drivers of cost and quality.
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Papers by Larry Hearld