1. Health Care Organizations from the Inside-Out EPI 247: INTRODUCTION Health Care Organizations from the Inside-Out EPI 247: INTRODUCTION Laura Schmidt, PhD, MSW,MPH Associate Professor Philip R. Lee Institute for Health Policy Studies and Department of Anthropology, History & Social Medicine

2. WHY STUDY SYSTEMS?

3. A Few Problems In Healthcare 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”?

4. WHY STUDY SYSTEMS? It’s not that we don’t have reasonable solutions to these problems… …It’s that we can’t actually implement those solutions in healthcare organizations.

5. WHY STUDY SYSTEMS? Learning how to diagnose what makes an organization tick is the only way figure out how to really fix these problems.

6. Who Knows About Systems? Sociologists of Organizational Behavior Business Management Researchers Industrial Engineers Institutional Economists Policy Researchers/Political Scientists in Implementation Sciences

7. GOALS FOR THIS CLASS To develop skills in how to: Diagnose problems in Healthcare organizations Find leverage points for constructive change

8. STRATEGIES FOR LEARNING 1. Brief introductions to different key approaches to understanding organizations 2. Weekly readings and class discussion of case studies in healthcare 3. Short, targeted weekly assignments that help you use the approach

9. ORGANIZATIONAL ANATOMY

10. KEY PARTS OF AN ORGANIZATION 1. Culture 2. Structure 3. Governance/Power Structure 4. Organizational Environment

11. 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

12. ORGANIZATIONAL CULTURE: Key Symptoms to Look For ORGANIZATIONAL CULTURE: Key Symptoms to Look For 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?

13. CULTURE: Lessons from Organization Research CULTURE: Lessons from Organization 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.

14. ORGANIZATIONAL STRUCTURE ORGANIZATIONAL 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

15. STRUCTURE: Key Symptoms to Look For STRUCTURE: Key Symptoms to Look For 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?

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

18. STRUCTURE: Lessons from Org. Research STRUCTURE: Lessons 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

19. GOVERNANCE/POWER: Key Questions to Ask Yourself GOVERNANCE/POWER: Key Questions to Ask Yourself 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?

20. POWER, AUTHORITY AND CONTROL POWER, 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.

21. GOVERNANCE: Lessons 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

22. ENVIRONMENT: Key Questions to Ask Yourself ENVIRONMENT: Key Questions to Ask Yourself 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?

23. ORGANIZATIONAL ENVIRONMENTS ORGANIZATIONAL ENVIRONMENTS Intra-Organizational Analysis: Anything that goes on inside the organization. Organizational Environment: The world comprised of other organizations outside the focal organization. Organizational Field: A system of organizations that stably interact, share common assumptions and goals, and have a role structure with winners and losers. Inter-organizational Analysis: Things going on between organizations or networks within fields

24. Organizations and Environments SFGH UCSF SOM CPMC Blue Cross of CA City of SF CMA CNA FEDS: NIH, CMS, FDA Pacific Business Group on Health

25. 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

27. ENVIRONMENT: Lessons from Org. Research Most healthcare organizations must adapt to their environments or die* 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

28. LEVERAGE POINTS FOR CHANGE LEVERAGE POINTS FOR CHANGE 1. Culture 2. Structure 3. Governance 4. Environment

29. DISCUSSION FOR NEXT WEEK: Case Studies DISCUSSION FOR NEXT WEEK: Case Studies As you see it, what is the biggest problem or failure in the organization you selected? Given where you were placed in the organization, what could you do about it?