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Strategizing to Address Healthcare Disparities Case 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 Grants 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 Teams 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 organizations 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 & Lukas for the Fieldstone Alliance
©Professor Lynn Perry Wooten, June 2007 Ross School of Business, University of Michigan Case Study Sites SiteBackground Information Catholic 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 citys 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 1 st Case Study Conduct Remaining Case Studies Select Cases Develop Theory Conduct 2 nd Case Study Design Data Collection Protocol interviews observations documents Write Individual Case Report interviews observations documents define process operationally define process out- comes (not just ultimate effects) use formal data collection techniques Write Individual Case Report Write Individual Case Report pattern-match policy implications pattern-match policy implications replication Modify Theory Develop Policy Implications Write Cross-Case Report Draw Cross-Case Conclusions 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
©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 Knowledge Resources Knowledge Resources Partners 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 SiteQualityDiversity/ 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 GovernmentWorkforce 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 – Disneys Approach to quality and customer service Undoing RacismPatient 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 SiteQualityDiversity/ Cultural Competencies Patient Engagement Data Driven National HMOCost ManagementHR 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 Organizatio n B Organization C Collective Leadership Through Diverse Partnerships Reduction in Healthcare Disparities 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 youve always done, youll always get what youve always got. If you want something youve never had, youve got to do something youve never done. (A.J. McKnight)
The difference between what we want and what we have got
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