1. Week 4 Epi. 211 Organizational and Community-Level Factors in Healthcare Performance Week 4 Epi. 211 Laura Schmidt, Ph.D, MSW, MPH Philip R. Lee Institute for Health Policy Studies and Department of Anthropology, History and Social Medicine

2. Why Worry About Organizational and Community- Level Factors in Healthcare Performance?

3. A Few Problems in Healthcare Performance 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 WORRY ABOUT ORGANIZATIONS? It’s not that we don’t often have reasonable solutions to these problems… …It’s that we often don’t do a good job of implementing these performance improvements. Implementation happens in real-world organizations and communities

5. Who Knows About Organizations? Sociologists of Organizational Behavior Business Management Researchers Industrial Engineers Institutional Economists Policy Researchers/Political Scientists “Implementation Scientists”

6. ORGANIZATIONAL ANATOMY

7. KEY PARTS OF THAT CAN INFLUENCE PERFORMANCE 1. Organizational Culture 2. Organizational Structure 3. Power Structure within the Organization 4. Organizational Environment

8. 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

9. ORGANIZATIONAL CULTURE: Key Symptoms of Performance Problems ORGANIZATIONAL CULTURE: Key Symptoms of Performance Problems 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?

10. 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.

11. 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

12. STRUCTURE: Key Symptoms of Performance Problems STRUCTURE: Key Symptoms of Performance Problems 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?

13. 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

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

16. 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

17. POWER STRUCTURE: Key Symptoms of Performance Problems POWER STRUCTURE: Key Symptoms of Performance Problems 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?

18. Defining POWER, AUTHORITY AND CONTROL Defining 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.

19. POWER: 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

20. 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

21. Defining Organizational Environments Environment supplies resources to organizations (money, people, power, legitimacy) Organizations are focused on survival not just performance Power flows to places within the organization that attract resources

22. 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

24. ENVIRONMENT: Key Issues in Performance ENVIRONMENT: Key Issues in Performance 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?

25. ENVIRONMENT: Lessons from Org. Research Most healthcare organizations must adapt to their environments or die—performance may not be the central goal 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 which can hamper or cover up poor performance

26. LEVERS FOR IMPROVING HEALTHCARE PERFORMANCE 1. Organizational Culture 2. Organizational Structure 3. Power Structure within the Organization 4. Organizational Environment