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This paper proposes an organizational change process to prepare physicians and other health professionals for their new roles in patient-centered medical homes (PCMHs). It provides physician-centered tools, models, concepts, and the language to implement transformational patient-centered medical care.

To improve care delivery, quality, and patient engagement, a systems approach to care is required. This paper examines a systems approach to patient care where all inputs that influence patient interactions and participation are considered in the design of health care delivery and follow-up treatment plans. Applying systems thinking, organizational change models, and team-building, we have examined the continuum of this change process from ideation through the diffusion of new methods and behaviors.

PCMHs make compelling business sense. Studies have shown that the PCMH improves patient satisfaction, clinical outcomes and reduces underuse and overuse of medical services. Patient-centered care necessitates transitioning from an adversarial to a collaborative culture. It is a transformation process predicated on strong leadership able to align an organization toward a vision of patient-centered care, creating a collaborative culture committed to health-goal achievement.

This paper proposes that the PCMH is a rigorous team-building transformational organizational change, a radical departure from the current hierarchical, silo-oriented, medical practice model. It requires that participants within and across health care organizations learn new skills and behaviors to achieve the anticipated quality and efficiency improvements. It is an innovative health care organization model of the future whose success is premised on teams supplanting the individual as the building block and unit of health care performance.

This paper examines the relationship between human resource practices in 173 hospitals in the United Kingdom and four organizational outcome categories – clinical, financial, employee attitudes and perceptions, and patient attitudes and perceptions. The overarching proposition set forth and examined in this paper is that human resource management (HRM) practices and delivery of care practices have varied effects on each of these outcomes. More specifically, the authors set forth the proposition that specific practices will have positive effects on one outcome category while simultaneously having a negative effect on other performance outcomes, broadly defined.

The paper introduces a broader stakeholder framework for assessing the HR–performance relationship in the healthcare setting. This multi-dimensional framework incorporates the effects of human resource practices on customers (patients), management, and frontline staff and can also be applied to other sectors such as manufacturing. This approach acknowledges the potential for incompatibilities between stakeholder performance objectives. In the healthcare industry specifically, our framework broadens the notion of performance.

Overall, our results provide support for the proposition that different stakeholders will be affected differently by the use of managerial practices. We believe that the findings reported in this paper highlight the importance of examining multiple stakeholder outcomes associated with managerial practices and the need to identify the inherent trade-offs associated with their adoption.

Longitudinally (2008–2012) assess whether community-level sociodemographic characteristics were associated with patient-centered medical home (PCMH) capacity among primary care and specialty physician practices, and the extent to which variation in PCMH capacity can be accounted for by sociodemographic characteristics of the community.

Linear growth curve models among 523 small and medium-sized physician practices that were members of a consortium of physician organizations pursuing the PCMH.

Our analysis indicated that the average level of sociodemographic characteristics was typically not associated with the level of PCMH capacity, but the heterogeneity of the surrounding community is generally associated with lower levels of capacity. Furthermore, these relationships differed for interpersonal and technical dimensions of the PCMH.

Our findings suggest that PCMH capabilities may not be evenly distributed across communities and raise questions about whether such distributional differences influence the PCMH’s ability to improve population health, especially the health of vulnerable populations. Such nuances highlight the challenges faced by practitioners and policy makers who advocate the continued expansion of the PCMH as a means of improving the health of local communities.

To date, most studies have focused cross-sectionally on practice characteristics and their association with PCMH adoption. Less understood is how physician practices’ PCMH adoption varies as a function of the sociodemographic characteristics of the community in which the practice is located, despite work that acknowledges the importance of social context in decisions about adoption and implementation that can affect the dissemination of innovations.

We use data from the American Time Use Survey (ATUS) to investigate racial differences in the amount of time individuals spend traveling to, waiting for, and receiving outpatient healthcare services on a randomly selected survey interview day. Of the 60,674 participants in the 2003–2006 waves of the ATUS, 2.67% (n=1,621) reported a clinical encounter on their designated day; this proportion did not differ significantly by race. Among those reporting a clinical encounter, blacks reported spending 30 more minutes than whites in receiving services, and this race gap persisted net of socioeconomic, health, and geographic factors. Hispanics also reported significantly longer visits than whites; yet, this difference was partially accounted for by Hispanics’ relatively poorer health status. Hispanics and persons of other ethnicity reported significantly longer wait times than whites, whereas blacks and Hispanics reported significantly longer travel times than did whites; these significant differences did not attenuate in the fully adjusted models. The results show that ethnic minorities spend far more time than whites when traveling to, waiting for, or receiving outpatient services, revealing another aspect of health care where stark racial inequities exist. We suggest that the relatively long wait and transportation times reported by ethnic minorities may reflect overcrowded care sites and the lack of quality care in neighborhoods inhabited largely by blacks and Hispanics, thus impeding the delivery of timely and “patient-centered” medical care.

This chapter integrates organization design and sustainability concepts to describe an accelerated transformational change at the Fairview Medical Group (United States).

A case study of the transformation at Fairview Medical Group’s primary care clinics was developed from interviews and first-person accounts of the change. Objective data regarding outcomes was used to evaluate the effectiveness of the redesign process.

The Fairview Medical Group developed an innovation and change capability to transform 35 primary care clinics in six months. All of the clinics were certified by the state of Minnesota as complying with their healthcare standards. Clinical outcomes, costs, and employee and physician engagement also increased. All of the improved measures are sustained.

Healthcare reform in the United States struggles because the organization design challenges are great and the change difficulties even greater. Fairview’s experience provides important evidence and lessons that can help advance our understanding of effective healthcare and create more sustainable healthcare systems. This chapter provides healthcare system administrators evidence and alternatives in the pursuit of implementation.

This study sought to identify the organizational factors associated with team and network effectiveness of the Athena Breast Health Network, a multi-site collaboration between five University of California health systems.

Providers, managers, and support staff completed self-administered surveys over three years. Statistical analyses at the network and medical center levels tested hypotheses regarding the correlates of effective teams and perceived network effectiveness over time.

Perceived team effectiveness was positively correlated with group culture and environments which support collaboration, negatively correlated with hierarchical culture, and negatively associated with professional tenure at year two. As measured by increasing team effectiveness scores over time and Athena’s potential impact on patient care, perceived network effectiveness was positively associated with team effectiveness.

Results do not allow us to conclude that a certain type of culture “causes” team effectiveness or that team effectiveness “causes” greater perceptions of progress over time. Subsequent studies should examine these variables simultaneously. Further research is needed to examine the role of payment incentives, internal reward systems, the use of electronic health records, public disclosure of performance data, and depth of leadership within each organization and within the network overall.

Focusing on group affiliation and participation may improve team member perceptions regarding effectiveness and impact on patient care.

Relatively little is known about the adaptive processes that occur within inter-organizational networks to achieve desired goals, and particularly the roles played by multi-disciplinary inter-professional teams. We studied a network comprising multiple campuses actively involved in better understanding, preventing, and treating a complex disease.

Organizational metrics – including rankings, ratings, and other forms of public assessment – are inextricably tied to uncertainty. Metrics are not only responses to uncertainty in the organizational environment, but they also create new forms of uncertainty within the organizations they evaluate. Given this, it is productive to consider these metrics in relation to the garbage can model of organizational decision making, a framework that was designed to provide insight into uncertain and ambiguous contexts. In this paper, the authors use the case of patient experience surveys to argue for the value of this model for understanding responses to metrics in particular conditions. Specifically, the authors demonstrate how the different features of the garbage can model manifest themselves within organizations managing numbers, and the authors then use these findings to discuss the measurement conditions that promote garbage can responses, the distinctive types of unintended consequences these responses might produce, and the implications of the garbage can model for the understanding of metrics more generally.

Workplace voice is well-established and encompasses behaviors such as prosocial voice, informal complaints, grievance filing, and whistleblowing, and it focuses on interactions between the employee and supervisor or the employee and the organizational collective. In contrast, our chapter focuses on employee prosocial advocacy voice (PAV), which the authors define as prosocial voice behaviors aimed at preventing harm or promoting constructive changes by advocating on behalf of others. In the context of a healthcare organization, low quality and unsafe patient care are salient and objectionable states in which voice can motivate actions on behalf of the patient to improve information exchanges, governance, and outreach activities for safer outcomes. The authors draw from the theory and research on responsibility to intersect with theories on information processing, accountability, and stakeholders that operate through voice between the employee-patient, employee-coworker, and employee-profession, respectively, to propose a model of PAV in patient-centered healthcare. The authors complete the model by suggesting intervening influences and barriers to PAV that may affect patient-centered outcomes.