VA Parker, CHQOER; JR Rising, MDRC; MP Charns, MDRC

Objectives: This inquiry was part of a study describing and evaluating the development of service line management, at both network and facility levels, in VHA. Our objective was to understand how managers at different levels perceived the effects of network-level service lines during early stages of implementation. In contrast to traditional management structures characterized by the division of labor along disciplinary lines within facilities (e.g. medicine, psychology), service line structures are organized around particular types of care (e.g. heart, cancer) or populations (e.g. women, homeless) across an entire network.

Methods: Site visits were conducted to 10 VISNs in 1999. In each VISN, semi-structured interviews were conducted with managers in specific roles. These included network director, network officers, and facility senior management, and included individuals with varying levels of involvement in the service line adoption decision. . Respondents were asked to describe their perceptions of service line outcomes thus far. Interview responses were manually transcribed. Two researchers independently coded each interview transcript for attributions of process and outcomes associated with service lines, in nine categories derived from the literature and from network performance goals. These categories were: guideline implementation, uniformity of care, care coordination, access and enrollment, cost and utilization, communication, competition, staff motivation, and professional issues. The number of positively coded categories was tallied for each interview, and the average of this measure was computed for each VISN, in order to assess the overall perception of service line management within the network’s management. The average number of positively coded categories in each VISN was then compared with the type of network service line structure adopted (e.g. task force, team, matrix, division).

Results: Network-level service lines range from weak, (cross-facility task forces with no authority) through intermediate levels such as cross-facility teams, to strong (cross-facility divisions in which individuals report to service line management at the network level and not to facility-based discipline managers). The four networks with only task forces had the lowest average numbers of positively perceived service line outcomes. The network with the most positively perceived outcomes was the only one extensively using the divisional structure in 1999. The two VISNs with teams and one with a matrix structure had more positive perceptions of service line outcomes than the VISNs using task forces.

Conclusions: Network leaders perceived service lines to be linked to improvements in several areas, and the degree of positive evaluation appears to be linked with the extent of service line development. This may indicate that structures where more authority is vested in the network-level service line lead to more significant improvements in these areas. Alternatively, it may reflect that managers who have implemented such structures are predisposed to view them as successful. Continuing analysis of quantitative indicators of performance at the network level will enable us to answer this question.

Impact: Network managers involved in more extensive organizational changes in their network structure in the form of service lines appear more likely to perceive positive effects of such changes. Whether this represents any real difference in performance requires further investigation.