strategizing to address healthcare disparities case studies of health system partnerships and...
TRANSCRIPT
Strategizing to Address Healthcare DisparitiesCase studies of health system partnerships and capacity building activities
Professor Lynn Wooten
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Agenda
• Introduction of the Research Project
• Framing the Research Issues
• The Case Studies• Lessons Learned &
Reflections
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
The NIH Roadmap is an integrated vision to deepen our understanding of biology, stimulate interdisciplinary research teams, and reshape clinical research to accelerate medical discovery and improve people's health.
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Historical Starting Point
The rate of infant mortality (widely accepted as an accurate index of general health) among Negroes is double that of whites.”
Where Do We Go From Here: Chaos or Community? (Dr. Martin Luther King, 1968)
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
The Public Health Problem
• According to "Health, United States, 2000," infant mortality rates are more than twice as high for African-Americans.
– Stillbirths– Low Birth Weight
(10% of African-American Infants)
– Pre-term Delivery (20% of African-American Infants)
~ Highest infant mortality rate In the developed world
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
In the Popular Press (Essence Magazine, November 2005; New York Times; April 22, 2007)
In Turnabout, Infant Deaths Climb in South
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
“Disparities in the health care delivered to race and ethnic minorities are real and are associated with worst outcomes in many cases, which are unacceptable. The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them.”
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
'U' study seeks to close gaps in prenatal care (Michigan Daily, October 13, 2004)
• Closing the gap of disparities has become a major goal for many government agencies, researchers, healthcare organizations and community groups. Although in the past decade prenatal care utilization rates have risen, decreasing the overall infant mortality rate, disparities in infant mortality and other perinatal outcomes between various ethnic and socio-economic groups continue to widen. Moreover, researchers have yet to explain all of the differences in birth outcomes experienced by African-Americans compared to other groups.
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
The Grant’s Goals
• Interdisciplinary research infrastructure to solve public health problems.
• Develop testable hypotheses for new effective approaches to public health problems
• Provide an effective mechanism for communicating research-based information to policy leaders, providers, and patients.
• Three core areas: patients, providers and leaders
• The Research Team (17 departments represented at UM)~ OB/GYN~ Genetics~ Nursing~ Midwifery~ Public Health~ Social Work~ Engineering~ School of Information~ Business~ Sociology~ Anthropology~ Medical History
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Thinking Outside the Box: The University of Michigan Roadmap Team’s Interdisciplinary Model
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
The Organizational Perspective – Research Questions
• How can health care systems change from inertia to action in reducing disparities in patient care? ~ How do health systems frame the problem and its
solutions?~ Why do health system address this problem?~ Who is involved in addressing this problem? Why?~ What are the capacity building and organizational
competencies associated with moving from inertia to action in reducing disparities in patient care?
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Research Methodology
• Case Study data collected from a “diverse” set of healthcare organizations~ Direct Observations~ On-site visits~ Interviews~ Archival Data
• Transcribed and Coded into NVivo• Analyzed using a template, grounded
theory approach
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Guiding Theories
• Organizational Routines~ Skills and capabilities of organizations and its members; the current
best practice in an industry; enable organizations to cope with complex problems (Nelson & Winter, 1982)
~ An executed capability for repeated performance that has been learned in response to selective pressures (Cohen, 1996).
• Positive Organizing (Wooten, 2004; Dutton & Glynn, 2007)~ Enable organizational resourcefulness~ Enhance organizational strengths and capabilities~ Expand organizational action repertoires~ Collective behavior and relational mechanisms
• Capacity Building~ The building of an infrastructure to efficiently address health
problems (Joffres, et al., 2004)~ The development of core skills, management practices, strategies,
and systems to enhance an organization’s effectiveness, sustainability and ability to fulfill its mission (Connolly, 2001)
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Capacity Building in Action:Case Studies of Best Practices
Model created by Connolly & Luka’s for the Fieldstone Alliance
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Case Study SitesSite Background InformationCatholic Health System One of the largest Catholic health systems in the
country. The system owns, manages and is affiliated with 20 acute care hospitals and two nursing homes in four states.
City Government A large city that in 2005 a mayoral task force was commissioned to imagine a city that could marshal its resources to address health disparities. Partners for this disparity project include hospitals, the Red Cross, universities, insurance companies, foundations, and the city’s public health department.
County Public Health System
A collaborative effort of public health agencies, corporations, hospitals, a university, and foundations to reduce ethnic and racial health care disparities, with a focus on infant mortality.
National Health Maintenance Organization
An integrated health care delivery system with 8.5 million members, 12,800 physicians and over 150,000 employees. It operates in 9 states with 37 medical centers and 431 medical office buildings.
Southwest Hospital A teaching hospital that provided $409 million in uncompensated care in 2006. Eighty percent of patients are ethnic minorities. Busiest maternity ward in the country.
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Conduct 1st
Case Study
Conduct Remaining Case Studies
Select Cases
Develop Theory
Conduct 2nd
Case Study
Design DataCollectionProtocol
•interviews
•observations
•documents
WriteIndividualCase Report
•interviews
•observations
•documents
•define “process” operationally
•define “process” out-comes” (not just ultimate effects)
•use formal data collection techniques
WriteIndividualCase Report
WriteIndividualCase Report
•pattern-match
•policy implications
•pattern-match
•policy implications
•replication
Modify Theory
Develop Policy Implications
Write Cross-CaseReport
Draw Cross-Case Conclusions
• etc. • etc.
The Design of Case Study Research (Yin,1989)
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Template Analysis – Thematically analyzing qualitative data
√ Defined a priori theme of capacity building and related codes.
√ Transcribed qualitative data√ Initial coding√ Produced iterative version of templates√ Applied template to case sites√ Created case studies based on capacity
building templates√ Through out the process quality checks
and reflections
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Framing: Mission, Vision & Strategy
• Framing organizational action through a mission, vision or strategy bring focus, direction and a guiding paradigm. Frames filter, help with sense-making, and provide a roadmap for taking action (Deal & Bolman, 2003; Ancona et al., 1999: Weick, 1995).
• Framing sends out a message to stakeholders
• Within the case study, organizations frame addressing healthcare disparities as:~ As an integral part
of their mission~ An action-based
public health initiative
~ A business case~ An access to care
issue
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Examples of Framing: Mission, Vision & Strategy
• Mission Driven~ “Through our exceptional health care services,
we reveal the healing presence of God” (Catholic Health System)
~ “Our mandate is to furnish medical aid and hospital care to indigent and needy persons residing in the hospital district” (Southwest Hospital)
• The Business/Market Differentiation Case~ Market Positioning -- “We are not a sick plan, but a
health plan” (National HMO)• Action based
~ “Not just another study… but important work being done on the local level to help solve the problem” (City Government)
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Example: Framing as A Public Health Problem
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Governance, Leadership & Strategic Relationships Through “Partnerships”
• At case studies, City Government and County Health Department leadership and governance emerged through a community health partnership (Weech-Maldonado, Benson & Gamin, 2003); Alexander et al, 2001)
~ Designed to build on strength of local knowledge about health problems and experiences in service delivery
~ Support collaboration between the health care system and the community
~ Partnerships encourage system thinking by taking a population view of health that incorporates disease-based and wellness-based models (Shortell, 1996)
~ Collateral leadership as a super-organizational phenomenon Enables partnerships to tap into diverse skills and resources through a division of roles (Denis, Lamothe, & Langley, 2001)
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Community Health Partnerships
• “More than one person or organization is necessary to improve public health … at a minimum academics, health practitioners, and ‘grassroots’ folks.” (County Health Department)
• “Local communities cannot solve this problem alone.This needs to be a priority at every level of government, and embraced by organizations throughout the public health and health care system.” (City Government)
Initiating Organization
Partners
Partners
Partners
Partners
Partners
Partners
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Partnering as Knowledge & Resource Brokering
• Knowledge brokering focuses on identifying and bringing together people interested in an issue, people who can help each other develop evidence based solutions (Hargadon, 2002; Canadian Health Service Research Foundation).
• Examples in the cases ~ National HMO convened a conference on topic inviting
competitors; adopted approach from national think tank~ Catholic Health System & County Health Department
brokered best practices and knowledge from other industries.
Initiating Organization
KnowledgeResources
KnowledgeResourcesPartners
or Funders
Partners& Clients
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Institutionalization & Organizational Learning of Best Internal Operations Management/Program Delivery
• Organizational learning is a natural consequence of capacity building through collective leadership. Individual leaders not only bring knowledge into the group, but also create knowledge through a learning cycle (Sandmann & Vandenberg, 1995).
• Internal operations and programs emerge from leaders searching for innovative ways to solve a problem, such as by recombining resources, challenging the status quo, or adopting new models (Argyis, 1977).
• This requires the involvement of leaders who possess a skill set to identify relevant information, assimilate it, and apply it toward a new programs or processes (Boal & Hooijberg, 2001).
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Internal Operations Management/Program Delivery
Case Site Quality Diversity/Cultural Competencies
Patient Engagement
Data Driven
Catholic Health System
Dominant Focus; Baldridge Metrics
Workforce diversity of health system workers
Community Outreach Programs
Data collection link to TQM and Baldridge Standards
City Government
Workforce diversity of health system workers; Cultural Competencies Training; anti-racism training
Patient Education; Accessing Care; Active participation in treatment
Comprehensive approach to data – race, disease, access, patient satisfaction
County Health Department
Friendly Access Program – Disney’s Approach to quality and customer service
Undoing Racism Patient Education; Access to care: Navigation of Health System; Coordination of Services
Geo-spatial by zip codes. FIMR
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Internal Operations Management/Program Delivery (Continued)
Case Site Quality Diversity/Cultural Competencies
Patient Engagement
Data Driven
National HMO Cost Management
HR focus on diversity and cultural competencies
Patient Education & Empowerment; Community Outreach
Targeted healthcare
Southwest Hospital
Standardization of Routines; Hierarchy; Protocol serves as a “medicine cookbook” based on clinical research; Re-engineered the delivery of babies.
Community Outreach
Patient focused as a technique for Managing healthcare
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Impact….Defined in different ways
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Capacity Building
Organizational Learning
Empowerment & Engagement
Organization A
Organization B
Organization C
Collective Leadership
Through Diverse Partnerships
Reduction in HealthcareDisparities
Access to Healthcare
Quality of Healthcare
Individual & Community Wellbeing
Modeling Partnerships & Capacity Building Activities: From Inertia to Action
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Lessons Learned: Health Systems Addressing Health Disparities
• Committed, collective and visionary leadership.
• Framing drives action.• The importance of collecting and
analyzing data.• Organizational Learning• Systematic, targeted, and structured
programs based on best practices and evaluation.
©Professor Lynn Perry Wooten, June 2007
Ross School of Business, University of Michigan
Closing Thought
“If you always do what you’ve always done, you’ll always get what you’ve always got. If you want something you’ve never had, you’ve got to do something you’ve never done.” (A.J. McKnight)