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Biomedical subjects

Thomas G Rundall

Publications and source records attributed to Thomas G Rundall.

17 recordsLinked to original sources
PubMed2006

Influence of primary care practice and provider attributes on preventive service delivery.

BACKGROUND: While visits to the doctor's office are appropriate times to advise patients on health behaviors, these opportunities are often missed. Lapses in care quality are no longer attributed solely to individuals, but are also increasingly understood to be the result of organizational factors. This research examines the influence that both practice and provider attributes have on the delivery of preventive services for health behaviors. METHODS: This study used data collected from the Prescription for Health initiative sponsored by the Robert Wood Johnson Foundation. Quantitative data on 52 primary care practices and 318 healthcare providers were gathered from September 2003 to September 2004, and were analyzed upon completion of data collection. Hierarchical linear modeling was used to examine associations between both practice and provider attributes and preventive service delivery. RESULTS: Practice staff participation in decisions regarding quality improvement, practice change, and clinical operations positively influenced the effect of work relationships and negatively influenced the effect of practice size on service delivery. Nurse practitioners and allied health professionals reported more frequent delivery of services compared to physicians. Last, use of reminder systems and patient registries were positively associated with preventive service delivery. CONCLUSIONS: This study offers preliminary support for staff participation in practice decisions as a positive aspect of teamwork and collaboration. Findings also suggest leveraging nonphysician clinical staff and organized clinical systems to improve the delivery of preventive services for health behaviors.

Adult↗
PubMed2006

Productivity and turnover in PCPs: the role of staff participation in decision-making.

BACKGROUND: Efforts to redesign primary care practices are beginning to address how decisions are made in the practice setting. This study contributes to these efforts by examining associations between staff participation in decision-making, productivity, and turnover in primary care practices. The study is informed by organizational theories of participation that emphasize cognitive and affective influences on employee output and behavior. METHODS: This research used data collected from primary care practices involved in a national initiative sponsored by the Robert Wood Johnson Foundation. Cross-sectional survey data on organizational structures and attributes among 49 practices were analyzed. Regression analysis was used to examine associations among practice productivity, staff participation in decision-making, and formal structures such as staff meetings. Associations between staff turnover and participative decision-making were also examined. RESULTS: Staff participation in decisions regarding quality improvement, practice change, and clinical operations was positively associated with practice productivity, whereas formal structures such as staff meetings were not. In addition, higher levels of participation in decision-making were associated with reduced turnover among nonclinicians and administrative staff. CONCLUSION: Examination of organizational features is increasingly recognized as a key to improving primary care performance. Study findings suggest that one important strategy may be implementation of a participative model emphasizing greater staff involvement in practice decisions. This may enhance information-sharing, work satisfaction, and commitment to organizational decisions, all of which can lead to beneficial outcomes such as increased productivity and stability in primary care practices.

Cross-Sectional Studies↗
PubMed2006

Evidence-based management reconsidered.

Reports of medical mistakes have splashed across newspapers and magazines in the United States. At the same time, instances of overuse, underuse, and misuse of management tactics and strategies receive far less attention. The sense of urgency associated with improving the quality of medical care does not exist with respect to improving the quality of management decision making. A more evidence-based approach would improve the competence of the decision-makers and their motivation to use more scientific methods when making a decision. The authors of this article consider a study of 68 U.S. health services managers that found a low level of evidence-based management behaviors. From the findings, four strategies are suggested to increase health systems managers' use of research evidence to improve decision making: focusing evidence-based decision making on strategically important issues, developing committees and other structures to diffuse management research throughout the organization, building a management culture that values research, and training managers in the competencies required to apply research evidence to health services management decisions. To aid the manager in understanding and applying an evidenced-based approach to decision making, the article provides practical tools, techniques, and resources for immediate use.

Decision Making, Organizational↗
PubMed2005

Kaiser Permanente's experience of implementing an electronic medical record: a qualitative study.

OBJECTIVE: To examine users' attitudes to implementation of an electronic medical record system in Kaiser Permanente Hawaii. DESIGN: Qualitative study based on semistructured interviews. SETTING: Four primary healthcare teams in four clinics, and four specialty departments in one hospital, on Oahu, Hawaii. Shortly before the interviews, Kaiser Permanente stopped implementation of the initial system in favour of a competing one. PARTICIPANTS: Twenty six senior clinicians, managers, and project team members. RESULTS: Seven key findings emerged: users perceived the decision to adopt the electronic medical record system as flawed; software design problems increased resistance; the system reduced doctors' productivity, especially during initial implementation, which fuelled resistance; the system required clarification of clinical roles and responsibilities, which was traumatic for some individuals; a cooperative culture created trade-offs at varying points in the implementation; no single leadership style was optimal--a participatory, consensus-building style may lead to more effective adoption decisions, whereas decisive leadership could help resolve barriers and resistance during implementation; the process fostered a counter climate of conflict, which was resolved by withdrawal of the initial system. CONCLUSIONS: Implementation involved several critical components, including perceptions of the system selection, early testing, adaptation of the system to the larger organisation, and adaptation of the organisation to the new electronic environment. Throughout, organisational factors such as leadership, culture, and professional ideals played complex roles, each facilitating and hindering implementation at various points. A transient climate of conflict was associated with adoption of the system.

Attitude of Health Personnel↗
PubMed2005

Drivers of electronic medical record adoption among medical groups.

BACKGROUND: Use of electronic medical records (EMRs) in health care organizations can reduce medical errors and improve quality of care through physicians' increased use of evidence-based patient care processes. However, only 20%-25% of physician organizations have adopted EMRs. A study was undertaken to determine the characteristics of primary care medical groups that distinguish EMR adopter from nonadopter organizations. METHODS: A quantitative nationwide survey was undertaken of all primary care medical groups in the United States with 20 or more physicians; data were collected on 738 medical groups (70% response rate). RESULTS: Fewer than one-third of the medical groups reported having either patients' medical records or progress notes in an EMR. Large organizations with relatively fewer practice locations were more likely to adopt an EMR. DISCUSSION: Large medical groups are more likely to have the financial and human resources necessary to overcome barriers to the adoption of an EMR. Knowing the influence of the other organizational characteristics on EMR adoption will help prepare organizational leaders for the complicated process of achieving consensus among physicians and others in medical groups on the expenditure of funds and other resources to acquire an EMR. Financial incentives for all medical groups will help drive EMR adoption, but financial and technical assistance aimed specifically at smaller groups is particularly warranted. Widespread adoption of EMR among medical groups will take time.

Data Collection↗
PubMed2005

The impact of hospitalists on the cost and quality of inpatient care in the United States: a research synthesis.

There is substantial disagreement regarding the impact of hospitalists on costs, quality, and satisfaction with inpatient care. The authors reviewed 21 evaluations of the use of hospitalists in U.S. hospitals. Most evaluations found that patients managed by hospitalists had lower total costs or charges than patients in comparison groups and that these savings were achieved primarily by reducing length of stay. Most evaluations found no statistically significant differences in quality of care or satisfaction. However, lack of random assignment limits the ability to draw causal inferences from many of the evaluations. All randomized studies were conducted in teaching hospitals, raising questions as to the generalizability of findings to nonteaching hospitals. Further research is needed to better identify the mechanisms by which hospitalists reduce length of stay and to ascertain which types of hospitalist programs are most effective and which patients are most likely to benefit.

Health Services Research↗
PubMed2005

An empirical assessment of high-performing medical groups: results from a national study.

The performance of medical groups is receiving increased attention. Relatively little conceptual or empirical work exists that examines the various dimensions of medical group performance. Using a national database of 693 medical groups, this article develops a scorecard approach to assessing group performance and presents a theory-driven framework for differentiating between high-performing versus low-performing medical groups. The clinical quality of care, financial performance, and organizational learning capability of medical groups are assessed in relation to environmental forces, resource acquisition and resource deployment factors, and a quality-centered culture. Findings support the utility of the performance scorecard approach and identification of a number of key factors differentiating high-performing from low-performing groups including, in particular, the importance of a quality-centered culture and the requirement of outside reporting from third party organizations. The findings hold a number of important implications for policy and practice, and the framework presented provides a foundation for future research.

Benchmarking↗
PubMed2004

Health promotion in physician organizations: results from a national study.

BACKGROUND: Health promotion programs can be effective in improving the delivery of clinical preventive services and in improving population health; however, the availability of health promotion programs offered through physician organizations, such as medical groups and independent practice associations, are largely unknown. METHODS: This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California, Berkeley, to document the extent to which physician organizations offer health promotion programs. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%. RESULTS: Overall, 60% of physician organizations offer at least one health promotion program targeting one or more of eight areas: prenatal education (42%), smoking cessation (39%), nutrition (39%), weight loss (34%), health risk assessments (25%), stress management (25%), substance abuse (20%), and sexually transmitted disease prevention (16%). Factors positively associated with offering health promotion programs include the following: outside reporting of quality measures, public recognition for quality measures, clinical information technology systems, being a medical group, and ownership by a hospital or health plan. CONCLUSIONS: Physician organizations in the United States have a long way to go in offering these important programs to their patients. However, our findings also suggest that health plans, purchasers, and policymakers can play a positive role in increasing the use of these programs. By offering recognition and incentives for quality improvement, and by funding the expansion of information technology, the healthcare community can encourage and enable physician organizations to increase the availability of health promotion programs nationally.

Data Interpretation, Statistical↗
PubMed2004

What are the facilitators and barriers in physician organizations' use of care management processes?

BACKGROUND: Care management processes (CMPs) such as disease registries, reminder systems, performance feedback, case management, and self-management education can improve chronic illness care, yet 50% of physician organizations have instituted few if any CMPs. METHODS: Site-visit interviews were conducted with 158 leaders at 15 physician organizations, with 3 organizations (1 large medical group, 1 small medical group, and 1 independent practice association [IPA]) chosen randomly in most cases in each of five communities. RESULTS: Seven of the 15 organizations had implemented CMPs minimally or not at all. CMPs were most common for diabetes and least common for depression; no IPAs had achieved significant CMP implementation for any of the conditions. The two most commonly mentioned facilitators were strong leadership and organizational culture valuing quality. The top five barriers were poor financial situation, reimbursement that does not reward high quality, inadequate information technology, physician resistance, and physicians being too busy. DISCUSSION: Strong leadership and a quality-valuing culture are important facilitators of improved chronic care, but if insurers do not reward chronic care improvement, it is unlikely that CMPs will become permanently institutionalized in physician organizations.

Asthma↗
PubMed2004

A theory of physician-hospital integration: contending institutional and market logics in the health care field.

This article proposes a theory of physician-hospital integration. The theory is developed by building on three streams of scholarship: "new" institutionalism, "old" institutionalism, and the theory of economic markets. The theory uses several key concepts from these theoretical frameworks, including the notions of environmental demands for legitimacy, market demands for efficiency, and agency. To enhance the predictive power of the theory, two new concepts are introduced: directionality of influence between institutional and market forces at the macro-societal level, and degree of separation of institutional and market domains at the local level--which add important predictive power to the theory. Using these concepts, a number of hypotheses are proposed regarding the ideal types of physician-hospital arrangements that are likely to emerge under different combinations of directionality of influence and institutional and market domain separation. Moreover, the theory generates hypotheses regarding organizational dynamics associated with physician-hospital integration, including the conditions associated with high and low prevalence of physician-hospital integration, the extent to which the integrated organization is physician-centric or hospital-centric, and whether physician-hospital integration is likely to be based on loose contractual arrangements or tight, ownership-based arrangements.

Efficiency, Organizational↗
PubMed2003

Support for smoking cessation interventions in physician organizations: results from a national study.

OBJECTIVES: To document the extent to which physician organizations, defined as medical groups and independent practice associations, are providing support for smoking cessation interventions and to identify external incentives and organizational characteristics associated with this support. METHODS: This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California at Berkeley, to document the extent to which physician organizations provide support for smoking cessation interventions. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%. RESULTS: Overall, 70% of physician organizations offered some support for smoking cessation interventions. Specifically, 17% require physicians to provide interventions, 15% evaluate interventions, 39% of physician organizations offer smoking health promotion programs, 25% provide nicotine replacement therapy starter kits, and materials are provided on pharmacotherapy (39%), counseling (37%), and self-help (58%). Factors positively associated with organizational support include income or public recognition for quality measures, financial incentives to promote smoking cessation interventions, requirements to report HEDIS (Health Plan Employer Data and Information Set) scores, awareness of the 1996 Clinical Practice Guideline on Smoking Cessation, being a medical group, organizational size, percentage of primary care physicians, and hospital/HMO ownership of the organization. CONCLUSION: Physician organizations are providing support for smoking cessation interventions, yet the level of support might be improved with more extensive use of external incentives. Financial incentives targeted specifically at promoting smoking cessation interventions need to be explored further. Additionally, emphasis on quality measures should continue, including an expansion of HEDIS smoking cessation measures.

Group Practice↗
PubMedDate not supplied

Effect of primary health care orientation on chronic care management.

PURPOSE: It has been suggested that the best way to improve chronic illness care is through a redesign of primary care emphasizing comprehensive, coordinated care as espoused by the Chronic Care Model (CCM). This study examined the relationship between primary care orientation and the implementation of the CCM in physician organizations. METHODS: The relationship between measures of primary care orientation and the CCM was examined in a sample of 957 physician organizations from the National Study of Physician Organizations, a cross-sectional telephone survey of all US medical groups and independent practice associations with 20 or more physicians (response rate, 70%). RESULTS: After adjusting for potential confounders, 6 of 8 measures of primary care orientation were associated with physician organizations' adoption of 11 elements of CCM chronic care management. These 6 measures were severity of chronic illness treated in primary care, health promotion activity, health education activity, any accepted financial risk for hospitalization, required reporting, and presence of an electronic standardized problem list. Presence of an electronic medical record and the 5-year primary care physician turnover rate were not associated. CONCLUSIONS: Organizations that have adopted 6 core attributes of primary care, representing comprehensive health service delivery and a commitment to overall patient health, appear to use more chronic care management practices. Policy makers and other stakeholders may wish to focus on creating an improved primary care home in their quest to close the "quality chasm" in chronic illness care.

Chronic Disease↗
PubMedDate not supplied

How different is California? A comparison of U.S. physician organizations.

Data from a national study of medical groups and independent practice associations are used to examine the extent to which California physician organizations are different from physician organizations in the rest of the United States. California physician organizations are different in many ways: most notably, they are more likely to have external incentives to improve quality and more likely to use recommended care management processes for treating patients with chronic illnesses. The implications of these differences for policy and practice are discussed.

California↗
PubMedDate not supplied

Doctor-manager relationships in the United States and the United Kingdom.

In many developed countries, including the United States and the United Kingdom, the relationships between doctors and hospital managers are strained. The purposes of this article are to examine survey data from the United States and the United Kingdom on doctor-manager relationships and to identify the sources of strain common to both countries as well as those particular to each country's health system. The two countries exhibited many similarities. A very high proportion of respondents from both countries identified external factors-such as governmental budget cuts, pressure from third parties to increase physicians' workload, and the turbulence of the policy environment-as important barriers to improving doctor-manager relationships. Other common sources of strain were concerns over resource availability and the relative power of doctors and managers. Sources of relationship tension particular to each country were also found. Substantial divergence of opinion was expressed with respect to internal factors that affect doctor-manager relationships. Respondents from the United States were more negative than those from the United Kingdom in their ratings of teamwork and communication between doctors and managers, and they were also less likely to have confidence in the medical staff. Respondents from the United Kingdom were more likely to believe that hospital management is driven more by financial than clinical priorities. Managers can implement several strategies to improve doctor-manager relationships, including greater organizational transparency in decision making; more frequent communication between managers and doctors; and more physician involvement in decision making, especially with regard to important resource-related decisions, and in organizational governance.

Communication↗