Exploring the Quality Chasm with Organizational Theory

NRSA Trainees Research Conference Slide Presentation (Text Version)

By Jon Chilingerian, Ph.D.

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On June 2, 2007, Jon Chilingerian made a slide presentation on exploring the quality chasm with organizational theory at the 13th Annual National Research Service Award (NRSA) Trainees Research Conference. This is the text version of the slide presentation. Select to access the PowerPoint® File (217 KB).

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Slide 1

Exploring the Quality Chasm with Organizational Theory

13th Annual NRSA Trainees
Research Conference
June 2, 2007

Professor Jon Chilingerian, Ph.D.
Schneider Institute for Health Policy
The Heller School for Social Policy and Management
Brandeis University

Pre-Doctoral Program Supported by Agency for Healthcare Research and Quality (AHRQ) Training Grant

Slide 2

Design Variables & Key Processes

This diagram shows key variables and processes in understanding the role of organizational theory in exploring the quality chasm. The diagram displays a central circle which includes key organizational processes. They include the following variables: Leadership and Career Development, Decision Making, Communication, Coordination, Change Management, Strategic Planning and Management Control, Performance Management.

Four sets of factors that influence and in turn are influenced by the key organizational processes are displayed as smaller circles outside of the larger one and circling it. These four sets of factors and variables or aspects important in each are captured as follows:

• One circle is entitled People and includes the following important variables: Task Related Competencies, Commitment and Motivation, Individual Needs, and Diversity.
• The second circle is entitled Work  and  includes the following important variables:  Technological Complexity  and Uncertainty, Intrinsic Motivation, Roles and Responsibilities, and Work Methods
• The third circle is entitled Formal Arrangements and includes the following important variables: Coordination Mechanisms, Division of Labor, Operating systems, HR (Human Resources) Policies and Practices, and Physical Space.
• The fourth circle is entitled Culture and Values and includes the following important variables: Norms, Values, Assumptions, Communication patterns, Political Alignments, Power and Influence, Leader behaviors, and Decision Rights.

Slide 3

Professional Behavior

This figure encompasses one large central circle entitled Professional Behavior. It is surrounded by 10 smaller circles, each indicating a key aspect which is influenced by professional behavior. These aspects are: training and CME, malpractice costs, prior socialization, financial incentives, patient needs and requests, colleagues, verbal requests, norms, care teams, Standard Operating Procedures (SOPs), and protocols.

Slide 4

Understanding the Quality Problem

The following three bullets are included in this slide:

• Diagnosis and analysis runs to the heart of the quality problem in health care.
• But there are too many organizational variables and never enough observations to predict anything precisely.
• Although system, structures, and process behavior can reduce some of the quality variations, professionals can overcome most influences and management controls.

Slide 5

Organizational Exploration of the Quality Chasm

This slide contains one major point indicated in the format of a bullet. The  bullet states: Quality is one of the most complex problems in health care.   Under the bullets are three major points, depicted as sub-bullets.

• The first point states: We believe that theory is important to understanding quality. Three aspects of this point are listed underneath it. They include: So far, we have not found a theoretically correct way to assess and analyze quality; Absent a guiding theory, one can think about quality from multiple social science perspectives; and Lack of widely accepted definitions.
• The second point states: Organizational theory offers many ways to look at and think about quality and it is critical that rival theories are pitted one against another.
• The third point states: An organizational theory will help us to craft new ideas and hypotheses about quality.

Slide 6

Diagram Showing An Organizational Theory Approach to Understanding Influences and Interactions Involving Selective Recruitment and Commitment to Goals, Strategy and Marketing and Relationships and Co-Production: Among Components of a Healthcare Firm; and Between the Firm, Clinical Providers and Patients

This slide shows an untitled diagram representing relationships and co-productions involving the healthcare firm, clinical providers and patients. The major figure is a large central triangle. The top angle of the triangle is entitled Firm, the left angle is entitled Clinical Providers, and the right angle is entitled Patients. There are two sets of environmental influences noted outside of the triangle, one on the upper left side and one on the upper right side. On the upper left side outside of the triangle, the Policy Environment is noted, which includes the Payment and finance system. On the upper right hand side outside of the triangle, the Social Environment is noted, which includes Norms and Values.

There are two-way arrows along each of the triangle sides, indicating that the firm, clinical providers, and patients influence each other and are influenced by each other in various ways, which are depicted outside the triangle. The firm and clinical providers are shown to influence each other through Selective Recruitment and Commitment to Goals. The firm and patients are seen to influence each other by strategy and marketing. Clinical providers and patients are shown to influence each other through relationships and co-production.

In the triangle itself is text, which indicates key aspects of organizational theory important in understanding the quality chasm. The top inside part of the triangle denotes the importance of leadership and the middle portion the organization of providers and care programs. The bottom inside portion of the triangle is a series of two rows, with the words micro-processes noted seven times and two-directional arrows connecting each set of micro-processes to each other.

Slide 7

Simplified Diagram Showing Relationship Between A Health Care Firm, Clinical Providers, and Patients

This slide shows a simplified version of Slide 6 above. It shows the upper-left hand side entitled Policy Environment, which includes the Payment and finance system. The triangle itself does have the three angles labeled Firm, Clinical Providers, and Patients. The only text inside the triangle itself is entitled Organization of Providers & Care Programs. There is a two-sided arrow between the policy environment and organizationan dcare of providers and care programs, which is noted in the middle part of the triangle. The slide depicts the importance of the policy environment in influencing and being influenced by organization of providers and care programs.

Slide 8

The Utility of Process Performance Measurement for Medicare Value Based Purchasing

Andrew Ryan

Schneider Institute for Health Policy
The Heller School for Social Policy and Management
Brandeis University

Slide 9

Simplified Diagram Showing Relationship Between A Healthcare Firm, Clinical Providers and Patients

This slide shows a simplified version of Slide 6 above. It shows the upper left hand side entitled Policy Environment: Payment and finance system. In addition, there is text between Firm and Clinical Providers on the left-side of the triangle entitled Selective Recruitment & Commitment to Goals. The triangle itself does have the three angles labeled Firm, Clinical Providers, and Patients. The only text inside the triangle itself is entitled Organization of Providers & Care Programs.

Slide 10

Improving Quality by Aligning Physicians: Exploring Substance Abuse Centers

Sayeda Haq

Slide 11

Simplified Diagram Showing Relationship Between A Healthcare Firm, Clinical Providers and Patients

This slide shows a simplified version of Slide 6 above. The triangle has three angles labeled Firm, Clinical Providers, and Patients. In the triangle itself is text. The tip of the triangle has text saying Leadership. Underneath that is text saying Organization of Providers & Care Programs. The bottom part of the triangle is two rows of two-sided arrows with the words Micro-care processes between the arrows.

Slide 12

Increasing Performance with More Effective Coordination

Farbod N. Hagigi, MPH, Ph.D. Candidate

Slide 13

Simplified Diagram Showing Relationship Between A Healthcare Firm, Clinical Providers and Patients

This slide shows a simplified version of Slide 6 above. It shows the upper right hand side entitled Social Environment: norms and values. In addition, there is text between Clinical Providers and Patients on the bottom of the triangle entitled Relationships & Co-Production. The triangle itself does have the three angles labeled Firm, Clinical Providers, and Patients.

Slide 14

Using Fair Process to Cross the Quality and Healthcare Chasm: Eliciting the Perspective of Traumatic Brain Injury Survivors

Laura S. Lorenz, M.A., M.Ed., Ph.D. Candidate
Schneider Institute for Health Policy,
The Heller School for Social Policy and Management,
Brandeis University

Slide 15

Diagram Showing Relationship Between A Healthcare Firm, Clinical Providers and Patients

This slide is a duplicate of Slide 6.

Slide 16

Care Coordination for Seniors with Multiple Chronic Diseases: Examining the Macro and Micro Level Relationships and Outcomes

Marian Ryan, R.R.T., M.P.H., CHES
Schneider Institute for Health Policy,
The Heller School for Social Policy and Management,
Brandeis University

Slide 17

People, Process & Authority Relations

This slide is a diagram showing the relationship between people, processes and authority relations. In the center of the diagram is the word People with four arrows pointing out to four different ovals. The top left oval is entitled Hawthorne effect, the bottom left is Cross-pressure hypothesis. The top right oval is entitled Interaction hypothesis, and the bottom right is entitled Participation hypothesis. There is a large oval around the four ovals. On the outside of the oval is four additional phrases that have arrows between them. The top right area says Morale & Productivity and has an arrow pointing to the bottom right entitled Rapid changes in human behavior, and an arrow pointing to the left to the left side entitled Performance. There is an arrow from that title to the bottom left entitled Frustration & Withdrawal. There is an arrow pointing upward from that title to the top left side entitled Performance.

Slide 18

Brandeis Emblem

This slide shows the Brandeis emblem. It is circular with the words Truth Even Unto Its Innermost Parts around the outer ring.

Slide 19

What is the Motivating Context: Strong/Weak/Distorted?

• Payment & Finance.
• Professional Norms.
• Leadership Behavior.
• Grouping of Units.
• Performance Standards.
• Reward Systems.
• Recruitment/Training.
• Management Control/Operating Systems.
• Political System and Decision Rights.
• Values and Norms.

Slide 20

Organizational Views on Quality

High Reliability

• Safety culture.
• Decentralize DM.
• Good design.
• Redundancy.
• Trial and error and simulations.

Normal Accidents

• Safety one of many competing objectives.
• Redundancy causes problems.
• Decentralization needed for complexity; however centralization needed for loosely coupled systems.

Current as of October 2007

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Internet Citation:

Chilingerian, J. Exploring the Quality Chasm with Organizational Theory. Text Version of a Slide Presentation. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/fund/training/chilingeriantxt.htm

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