Prelims

Addressing Challenges – Moving Knowledge to Action

Good morning, America! Welcome to the world of climate-induced fires and floods, ongoing pandemics, persistent gun violence, and global conflict. Lacking the political will and national capabilities for prevention and safeguarding the public's health, the health care ecosystem becomes the default option and “first responder” to these and related challenges. Further, hospitals and physician organizations are often disproportionately blamed for poor population health outcomes that are more influenced by organizations and sectors involved with the underlying social determinants of health. The first victim of such events is a person's health and, collectively, the health of the population. The COVID-19 pandemic alone has reduced life expectancy in the United States from 79 to 77 years (Woolf, Masters, & Aron, 2021), with still-to-be-determined effects on people's health over their life course.

We live in a world of wicked problems where in many cases we do not even know what it is that we do not know. We are now two-years post-COVID and we have not identified the right national approach taken by the United States or any other country, or whether any of the steps taken a century ago to deal with the 1918 influenza pandemic should have been adopted or would have worked better. This does not sound like a “learning” system.

The goal of research is to reduce such uncertainty and produce some understanding about what to do. But “what to do” is often context dependent, subject to the need for customization across multiple settings and circumstances. One-size solutions “do not fit all.” Health care leaders and managers from both the policy and practice worlds are crying out: “Help us solve these wicked problems! We need systems that are responsive! Help us find solutions that get us out of this mess that we are in! We want to create a safer, healthier future” (Janoff, 2021).

At the 2020 Organization Theory in Health care Conference (OTHC) about 50 scholars came together to reflect on the field to date and discuss future needs (Nembhard et al., 2020). Among the areas identified for needed research were cross-sector partnerships targeting the social determinants of health; the role of networks within and across health care organizations; applications of artificial intelligence (AI) and machine learning (ML) in health care provision and population health management; health care organization governance and accountability; and the need for more research that addresses the multiple levels of health care organizations.

The recent 20th volume of Advances in Health Care Management (Hefner & Nembhard, 2021) began to address some of the topics highlighted at OTHC within the framework of grand challenges. The current 21st volume builds on and extends those insights and recommendations by systematically identifying areas where actionable knowledge is needed across a variety of issues. These include responding to unexpected events, accelerating innovations to improve performance, building effective strategic alliances with other sectors that “produce” health, and exploring the challenges of AI and the digital world, among others. Volume 20 summarized much of the existing and emerging knowledge on some of these topics. The current volume identifies the remaining gaps in knowledge; presents research agendas for filling those gaps; and thereby, potentially reduces some of the uncertainty inherent in living in a world of wicked problems.

Overview of the Papers in This Volume

Table 1 provides a quick overview of each chapter. Chapter 1, “Responses to Unexpected Events,” by Bradley and Alamo-Pastrana builds on the Volume 20 chapters on the impact of COVID-19 through the lens of building organizational resilience. The authors use the experience of addressing COVID-19 at Vassar College to highlight the behaviors needed to motivate and sustain resistance to such events. The importance of wide-spread environmental scanning, transparent communication, continuous learning, and accepting failures as opportunities for improvement are identified. Chapter 1 calls for research that assesses the impact of short-term versus long-term crises; external versus internal shocks; and the impact of crises on the pace of innovation and change. The authors underscore the need for longitudinal research using natural experiments to “illuminate the full cycle of crises across organizations from anticipation to response, to longer term adaptation to the ‘new normal.’”

In Chapter 2, Hung, Lee, and Rundall address the question of why enterprise-wide transformational improvement has been so slow to be adopted and implemented in US health care organizations. Given the pervasive change that such an approach entails, organizations are understandably reluctant to make them in the absence of evidence that such changes will result in improved performance and that such improvement will be rewarded. In reviewing the existing literature, the authors note that the evidence for the effectiveness of such organization-wide approaches is just beginning to emerge. The authors suggest a number of research designs with the potential to generate greater knowledge including interrupted time series, multiple baseline designs, and stepped wedge designs. They suggest the use of the Consolidated Framework for Implementation Research for Process Redesign (CFIR-PR) to help guide future research. They draw on the whole system transformation experience of the Veterans Administration Health System to identify salient barriers and facilitators to transformational performance improvement implementation.

Chapter 3 by Øvretveit presents an innovative approach for combining quality improvement science and implementation science to accelerate the testing and spread of health care delivery innovations. Called “Improve-mentation,” the author illustrates its use in evaluating an emergency response system to address the COVID-19 pandemic, offering additional lessons to those discussed in Chapter 2. Four Improve-mentation frameworks are suggested with knowledge gaps and research strategies for addressing those gaps identified for each framework. Øvretveit emphasizes the importance of developing the competencies and capacities to conduct such evaluations and what can be done to spread innovations and their implementation. Given the growing rapidity of external shocks facing health care organizations, there is great need for such rapid impact research.

The ability to address crises and improve performance is heavily influenced by the availability and analysis of data. In Chapter 4 Cross, Adler-Milstein, and Holmgren take on the challenges presented by the new digital technologies involved in health care delivery. Drawing on the lessons learned from the adoption and implementation of enterprise-wide electronic health records (EHRs), the authors highlight the challenge of addressing the inherent tension between standardization and flexibility/customization. They discuss the need to address this tension within the context of emerging artificial intelligence (AI) and machine learning (ML) applications. The need for research on algorithmic bias, shifting data sets, and ongoing evaluation of AI applications are discussed. The role played by governance structures, organizational leadership, and change management in addressing implementation barriers are called out as they are influenced by payment and regulatory forces.

Given the growing emphasis on the social determinants of health associated with overall population health, health care policymakers and practice leaders are giving increased attention to building partnerships between their organization and community-based social service organizations. Chapter 5 by Murray and Lewis addresses the increased importance of generating knowledge about developing effective strategic alliances between health care organizations and those operating in the social services sector – education, food, housing, and related. The authors underscore the disconnect between the broad literature on strategic alliances and that specific to the health care sector. Organizing the chapter around the life cycle framework to studying alliances, they call out the need for better theorizing including the development of typologies and examining the impact of public policies on alliance formation and performance. In particular, they highlight the need for research on multi-stakeholder alliances in which participants may have little prior experience in working together and with diverse funding sources to achieve goals.

Wicked problems may need to be addressed by organizations whose forms are themselves “seemingly wicked” due to their pluralistic and networked structure. As discussed in Chapter 6 by Hearld and Westra, networks attempt to address these challenges via emergent, bottom-up approaches whereby diverse stakeholders work collaboratively to define the problem(s) and implement solutions. That is, wicked problems that resist easy solutions (e.g., the triple aim, simultaneously achieving higher quality lower cost, and better patient experience) may require organizations with structures that resist clear differentiation, rules, and patterns of activity. Networks fit this description, since they rest on “relational ties”, interactions, and collaboration among many diverse parties – who are not used to working together or in such relationships. Researchers themselves are not used to studying many of the complex organizational forms such as accountable care organizations (ACOs) or integrated delivery networks (IDNs) for what they really are: “networked” organizations. Hearld and Westra push this field of inquiry forward by identifying a key ingredient that has been “missing in action” in the study of such networks: governance. Governance is such a key issue because ACOs and IDNs pull together parties who have heretofore operated as silos. Their chapter supplies much-needed clarity on what needs to be studied within these complex structures housing multiple firms and professions. They identify four main gaps in current research understanding of networks and their governance, and then analyze the challenge of studying them over time and across levels of analysis.

Chapter 7 by Landon continues this theme by examining how such networked organizations motivate and incentivize the key professional actors within them: the physicians. The chapter clearly establishes that economics-based approaches that rely on financial incentives – popularly known today as alternative payment models (APMs) – are insufficient. More is needed; and, in a networked organization, it will not come top-down from the C-Suite. The problems are multifactorial and emanate both from without and from within health care organizations. They might be quickly summarized as the presence of multiple conflicts: conflicts among payers in their reimbursement methods, conflicts in the incentives between payers and providers, and conflicts between professionals and the bureaucracies they work in. Hospital organizations have responded using a set of common strategies, such as hospital systems, vertical integration, and just plain getting bigger. These have generally not produced higher quality or lower cost of care. The solution may instead lie in how to organize the professional practice of medicine inside the institution. The required approach will be more horizontal than vertical, more distributed rather than uniform, and more noneconomic than economic. According to the chapter, the solution will need to be tailored to specific specialties, to incorporate nonfinancial incentives, and to mesh with the professional culture of medical groups. Such factors (and others) require study to determine the conditions under which APMs and other well-worn efforts (e.g., EMRs, care management) will work.

Chapter 8, by Sieck and colleagues, presents the movement toward patient engagement in health care. They first review the status of the field of patient engagement, including the high hopes for it to improve quality, reduce cost, promote patient satisfaction, and reduce inequities in care. One way to reach the goal of highly engaged patients is for health care systems to engage in interventions to boost and facilitate patient engagement. The success of these interventions is dependent on defining and measuring patient engagement, and also in understanding the lives of and barriers facing each patient. Social needs screening is an important element of patient engagement work. Thus, section 2 of this chapter presents a detailed case study of the incorporation of social needs screening into the digital infrastructure of a group of primary care practices in the Midwest. Facilitators and barriers to successful implementation are discussed and areas for future research are highlighted.

In Chapter 9, Williams, Silvera, and Lemak tackle perhaps THE issue of the day: diversity, equity, and inclusion (DEI). The central question is what organizations can do on the inside to address disparities in health and outcomes experienced by disadvantaged groups on the outside. This calls for a completely new mental model on the part of health care organizations and professions – one that is patient- and community-centric rather than being provider-centric. Given our collective ignorance about this enormously important topic, the authors define what the key terms in DEI are, how health care organizations negatively impact them, and what collaborative efforts are required to address these problems. The authors' emphasis, and key takeaway, centers on “learning” about the sources, nature, and solutions to the problem.

Concluding Thoughts

Implicit in the thinking and recommendations of this volume is the recognition of three pervasive underlying problems with the United States health care system. In brief, it is unnecessarily complex, overly fragmented, and plagued by misaligned incentives. If it is the case that every system is perfectly designed for what it is intended to do, then the US health care system is perfectly designed to produce high cost, uncoordinated, and highly varying quality of care that leaves patients and providers alike exhausted. As evidenced by the chapters that follow, this hinders responsiveness to unexpected events, the ability to improve performance, to engage patients and reduce inequities in care, to form effective partnerships with other sectors, and to take advantage of new digital technologies and payment models.

The chapters in this Volume, of course, are not all the areas in need of managerial/organizational research. Among the topics not considered are new developments in leadership research, advances in research on health care teams, professional and staff burnout, supply chain management, and research on new care delivery models such as “Hospital at Home.”

Specific topics aside, we want to call out the need for more research that addresses the multiple levels of organizations (micro, meso, and macro); the relational processes and structures associated with social networks involved in delivering care; that take advantage of emerging new data sets becoming available in many states with All Payer Claims Data Bases (APCDs) and the Agency Health care Research and Quality's (AHRQ) Compendium of Health care Systems; and the need for greater coproduction of knowledge through engaging with delivery organizations, community groups, and leaders who are the ultimate users of our research. We believe that giving greater attention to these issues will accelerate the knowledge base that can be used to improve the performance of organizations operating in the health care sector and, in particular, eliminate inequities in care.

Stephen M. Shortell

Robert L Burns

Editors