Organizational and Community-Level Factorsin Healthcare Performance

Week 4Week 4Epi. 211Epi. 211

Laura Schmidt, Ph.D, MSW, MPH

Philip R. Lee Institute for Health Policy Studies and Department of Anthropology, History and Social

Medicine

Why Worry AboutOrganizational and Community-

Level Factors in Healthcare Performance?

A Few Problems in Healthcare Performance

• Why can’t we improve patient safety?• Why can’t we integrate services to do a better job at treating chronic

disease?• Why can’t we lower costs without sacrificing quality?• Why can’t we reduce administrative waste?• Why can’t we equitably distribute services?• Why can’t we reduce ER overcrowding?• Why can’t we increase numbers of primary care doctors?• Why can’t we reduce the huge variations in care and costs across

regions of the country?• Why can’t we change “the culture of medical practice”?

WHY WORRY ABOUT WHY WORRY ABOUT ORGANIZATIONS?ORGANIZATIONS?

It’s not that we don’t often have reasonable solutions to these problems…

…It’s that we often don’t do a good job of implementing these performance improvements.

Implementation happens in real-world organizations and communities

Who Knows About Organizations?

• Sociologists of Organizational Behavior• Business Management Researchers• Industrial Engineers• Institutional Economists• Policy Researchers/Political Scientists• “Implementation Scientists”

ORGANIZATIONALANATOMY

KEY PARTS OF THAT CAN KEY PARTS OF THAT CAN INFLUENCE PERFORMANCEINFLUENCE PERFORMANCE

1. Organizational Culture

2. Organizational Structure

3. Power Structure within the Organization

4. Organizational Environment

ORGANIZATIONAL CULTURE ORGANIZATIONAL CULTURE

CULTURE= “A shared way of life.”

-shared language, behavior patterns, communication rituals

-common sense of mission and goals

-shared institutional history (not necessarily written down)

-”taken-for-granted” assumptions-tacit understandings that nobody questions

ORGANIZATIONAL CULTURE: ORGANIZATIONAL CULTURE:

Key Symptoms of Key Symptoms of Performance ProblemsPerformance Problems

• What is the professed goal of the organization?

• Does the organization spend most of its energy pursuing that goal?

• If not, what was the main goal people pursue?

CULTURE: Lessons from CULTURE: Lessons from Organization ResearchOrganization Research

• Every organization has a core managerial problem it is set up to solve

• Most organizations have multiple goals– some spoken, others are tacit and varied

• “Goal displacement” is a common disease

• The real goal of most organizations is to survive

• Organizational culture is hard to change because it is part of the survival strategy.

ORGANIZATIONAL ORGANIZATIONAL STRUCTURE STRUCTURE

SOCIAL STRUCTURE= “A Relatively fixed pattern in social life.”

• Size: number of people, amount of infrastructure

• Hierarchy: centralization, role structure

• Complexity: number of sub-units, technical complexity of tasks

• Interdependency: feedback between sub-units, built-in redundancies, checks and balances

STRUCTURE: STRUCTURE: Key Symptoms of Key Symptoms of

Performance ProblemsPerformance Problems

• What is the size, hierarchy, degree of complexity and interdependency in the organization?

• What is the optimal structure for the goals and tasks it wishes to pursue?

STRUCTURE: STRUCTURE: Lessons from Org. ResearchLessons from Org. Research• Structure is often determined by forces outside

the organization; this is often why it’s not optimal*

• Top-down bureaucracies work well for routine tasks and therefore, are often poorly suited to structures for most health care organizations

• Highly complex, interdependent organization (i.e. most healthcare organizations) avoid small problems at the risk of catastrophic failure

Managed care= combining provider and insurance functions in one organization or network of organizations

STRUCTURE: STRUCTURE: Lessons from Org. ResearchLessons from Org. Research• Structure is often determined by forces outside

the organization; this is often why it’s not optimal*

• Top-down bureaucracies work well for routine tasks and therefore, are often poorly suited to structures for most health care organizations

• Highly complex, interdependent organization (i.e. most healthcare organizations) avoid small problems at the risk of catastrophic failure

POWER STRUCTURE: POWER STRUCTURE: Key Symptoms of Key Symptoms of

Performance ProblemsPerformance Problems

• To whom does power flow in the organization?

• To what extent should decision-making be routinized?

• To what extent do informal rules (off-the-books practices) govern decision-making?

Defining POWER, Defining POWER,

AUTHORITY AND CONTROL AUTHORITY AND CONTROL

POWER= The ability to impose one’s will on someone else.

AUTHORITY=The routinization of power based on an assumption of legitimacy.

CONTROL= Fixed, built-in systems that maintain constrain subordinates automatically and invisibly.

POWER: POWER: Lessons from Org. ResearchLessons from Org. Research• Power flows to those units/people that bring

resources into the organization

• The work of healthcare professionals cannot easily be routinized—controlling clinicians while giving them discretion is the core managerial problem

• Informal rules and procedures that allow people to work around the power/control structure are often critical to the success of organizations

The Health Care Market: Role Structure

Large Employers

Government Insurance Plans

(e.g., Medicare, Medicaid)

Managed Health Plans(e.g., HMOs, PPOs)

Hospital Corporations“Providers” and

“Consumers”

HC Producers

Purchasers

Defining Organizational Environments

Environment supplies resources to organizations (money, people, power, legitimacy)

Organizations are focused on survival not just performance

Power flows to places within the organization that attract resources

Organizations and Organizations and EnvironmentsEnvironments

UCSFSOM

CPMC

Blue Cross of CA

City of SFCMA

CNA

FEDS: NIH, CMS, FDA

Pacific Business Group on Health

ENVIRONMENT: ENVIRONMENT: Key Issues in PerformanceKey Issues in Performance

• What players in the environment are critical to the organization’s survival?

• How does the organization stay legitimate?

• How much influence does the organization have over key parts of its environment?

ENVIRONMENT: ENVIRONMENT: Lessons from Org. ResearchLessons from Org. Research• Most healthcare organizations must adapt to their

environments or die—performance may not be the central goal

• Government is key to understanding health care environments: it’s a source of resources, regulations and legitimacy

• “Fitting in” to the environment is important, but for most organizations

• There’s a lot of window dressing involved which can hamper or cover up poor performance

LEVERS FOR IMPROVING LEVERS FOR IMPROVING HEALTHCARE HEALTHCARE

PERFORMANCEPERFORMANCE

1. Organizational Culture

2. Organizational Structure

3. Power Structure within the Organization

4. Organizational Environment