The organizational dynamics enabling patient portal impacts upon organizational performance and patient health: a qualitative study of Kaiser Permanente.

BackgroundPatient portals may lead to enhanced disease management, health plan retention, changes in channel utilization, and lower environmental waste. However, despite growing research on patient portals and their effects, our understanding of the organizational dynamics that explain how effects come about is limited.MethodsThis paper uses qualitative methods to advance our understanding of the organizational dynamics that influence the impact of a patient portal on organizational performance and patient health. The study setting is Kaiser Permanente, the world's largest not-for-profit integrated delivery system, which has been using a portal for over ten years. We interviewed eighteen physician leaders and executives particularly knowledgeable about the portal to learn about how they believe the patient portal works and what organizational factors affect its workings. Our analytical framework centered on two research questions. (1) How does the patient portal impact care delivery to produce the documented effects?; and (2) What are the important organizational factors that influence the patient portal's development?ResultsWe identify five ways in which the patient portal may impact care delivery to produce reported effects. First, the portal's ability to ease access to services improves some patients' satisfaction as well as changes the way patients seek care. Second, the transparency and activation of information enable some patients to better manage their care. Third, care management may also be improved through augmented patient-physician interaction. This augmented interaction may also increase the 'stickiness' of some patients to their providers. Forth, a similar effect may be triggered by a closer connection between Kaiser Permanente and patients, which may reduce the likelihood that patients will switch health plans. Finally, the portal may induce efficiencies in physician workflow and administrative tasks, stimulating certain operational savings and deeper involvement of patients in medical decisions. Moreover, our analysis illuminated seven organizational factors of particular importance to the portal's development--and thereby ability to impact care delivery: alignment with financial incentives, synergy with existing IT infrastructure and operations, physician-led governance, inclusive decision making and knowledge sharing, regional flexibility to implementation, continuous innovation, and emphasis on patient-centered design.ConclusionsThese findings show how organizational dynamics enable the patient portal to affect care delivery by summoning organization-wide support for and use of a portal that meets patient needs

Benchmarking outcomes on multiple contextual levels in lean healthcare : a systematic review, development of a conceptual framework, and a research agenda

Background Reliable benchmarking in Lean healthcare requires widely relevant and applicable domains for outcome metrics and careful attention to contextual levels. These levels have been poorly defined and no framework to facilitate performance benchmarking exists. Methods We systematically searched the Pubmed, Scopus, and Web of Science databases to identify original articles reporting benchmarking on different contextual levels in Lean healthcare and critically appraised the articles. Scarcity and heterogeneity of articles prevented quantitative meta-analyses. We developed a new, widely applicable conceptual framework for benchmarking drawing on the principles of ten commonly used healthcare quality frameworks and four value statements, and suggest an agenda for future research on benchmarking in Lean healthcare. Results We identified 22 articles on benchmarking in Lean healthcare on 4 contextual levels: intra-organizational (6 articles), regional (4), national (10), and international (2). We further categorized the articles by the domains in the proposed conceptual framework: patients (6), employed and affiliated staff (2), costs (2), and service provision (16). After critical appraisal, only one fifth of the articles were categorized as high quality. Conclusions When making evidence-informed decisions based on current scarce literature on benchmarking in healthcare, leaders and managers should carefully consider the influence of context. The proposed conceptual framework may facilitate performance benchmarking and spreading best practices in Lean healthcare. Future research on benchmarking in Lean healthcare should include international benchmarking, defining essential factors influencing Lean initiatives on different levels of context; patient-centered benchmarking; and system-level benchmarking with a balanced set of outcomes and quality measures.Peer reviewe

Analysis of small-diameter wood supply in northern Arizona - Final report

Forest management to restore fire-adapted ponderosa pine ecosystems is a central priority of the Southwestern Region of the USDA Forest Service. Appropriately-scaled businesses are apt to play a key role in achieving this goal by harvesting, processing and selling wood products, thereby reducing treatment costs and providing economic opportunities. The manner in which treatments occur across northern Arizona, with its multiple jurisdictions and land management areas, is of vital concern to a diversity of stakeholder groups. To identify a level of forest thinning treatments and potential wood supply from restoration byproducts, a 20-member working group representing environmental non-governmental organizations (NGOs), private forest industries, local government, the Ecological Restoration Institute at Northern Arizona University (NAU), and state and federal land and resource management agencies was assembled. A series of seven workshops supported by Forest Ecosystem Restoration Analysis (ForestERA; NAU) staff were designed to consolidate geographic data and other spatial information and to synthesize potential treatment scenarios for a 2.4 million acre analysis area south of the Grand Canyon and across the Mogollon Plateau. A total of 94% of the analysis area is on National Forest lands. ForestERA developed up-to-date remote sensing-based forest structure data layers to inform the development of treatment scenarios, and to estimate wood volume in three tree diameter classes of 16" diameter at breast height (dbh, 4.5' above base). For the purposes of this report, the group selected a 16" dbh threshold due to its common use within the analysis landscape as a break point differentiating "small" and "large" diameter trees in the ponderosa pine forest type. The focus of this study was on small-diameter trees, although wood supply estimates include some trees >16" dbh where their removal was required to meet desired post-treatment conditions.4 There was no concurrence within the group that trees over 16" dbh should be cut and removed from areas outside community protection management areas (CPMAs)..

Validation of the Lean Healthcare Implementation Self-Assessment Instrument (LHISI) in the finnish healthcare context

Lean management is growing in popularity in the healthcare sector worldwide, yet healthcare organizations are struggling with assessing the maturity of their Lean implementation and monitoring its change over time. Most existing methods for such assessments are time consuming, require site visits by external consultants, and lack frontline involvement. The original Lean Healthcare Implementation Self-Assessment Instrument (LHISI) was developed by the Center for Lean Engagement and Research (CLEAR), University of California, Berkeley as a Lean principles-based survey instrument that avoids the above problems. We validated the original LHISI in the context of Finnish healthcare.Background Lean management is growing in popularity in the healthcare sector worldwide, yet healthcare organizations are struggling with assessing the maturity of their Lean implementation and monitoring its change over time. Most existing methods for such assessments are time consuming, require site visits by external consultants, and lack frontline involvement. The original Lean Healthcare Implementation Self-Assessment Instrument (LHISI) was developed by the Center for Lean Engagement and Research (CLEAR), University of California, Berkeley as a Lean principles-based survey instrument that avoids the above problems. We validated the original LHISI in the context of Finnish healthcare. Methods The original HISI survey was sent over a secure organizational email system to the over 26,000 employees of the Hospital District of Helsinki and Uusimaa in March 2020. The data were randomly split with one part used to carry out an exploratory factor analysis (EFA), and the other for testing the resulting model using confirmatory factor analysis (CFA). Results A total of 6073 employees responded to the LHISI survey, for an overall response rate of 23%. The results indicated that the 43 items used in the original LHISI can be reduced to 25 items, and these items measure a five-dimensional model of the progress of Lean implementation: leadership, commitment, standard work, communication, and daily management system. In comparison with a single-factor model, the fit measures for the 5-factor model were better: smaller X-2, larger comparative fit index (CFI), smaller root mean square error of approximation (RMSEA), and smaller standardized root mean square residual (SRMR). Conclusions The 25 item LHISI is valid and feasible to use in the context of Finnish healthcare. The LHISI allows the organization to self-monitor the progress of its Lean implementation and provides the leadership with actionable knowledge to guide the path towards Lean maturity across the organization. Our findings encourage further studies on the adoption and validation of the LHISI in healthcare organizations worldwide.Peer reviewe

Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system

<p>Abstract</p> <p>Background</p> <p>Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system.</p> <p>Methods</p> <p>Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models.</p> <p>Results</p> <p>More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration.</p> <p>Conclusions</p> <p>More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.</p

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

The Commonwealth Fund of New York supported Tim Scott through a Harkness Fellowship. The Garfield Foundation provided funding for the data collection.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 die 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.Publisher PDFPeer reviewe

A Minimalist Organization Functioning in a Turbulent Environment

An observational study of the Oakland Eligible Metropolitan Area (EMA) and its Ryan White Title I HIV health services planning council, officially known as the Alameda/Contra Costa HIV Planning Council, has been in progress since October 1992. This paper reports on the background, methodology, and several preliminary findings of this research. It is argued that a Title I planning council's organizational form fits precisely the definition of a minimalist organization, and that the environment in which a planning council must function is turbulent. We identify several aspects of a planning council's turbulent environ- ment and the consequences for a planning council of a catastrophic loss of experienced and knowledgeable membership. We note that both internal and external environmental forces can seriously impair a planning council's functioning as an organization, or even culminate in its dissolution or sudden collapse, to be followed by its swift replacement by a newly appointed successor planning council. Furthermore, the planning council replacement procedure that we identify, when adroitly performed, apparently can be completed without jeopardizing either the EMA's Title I status and eligibility or the delivery of Title I-funded health and social services in the EMA. We conclude that the planning council replacement procedure is an example of environmental selection as hypothesized by theorists of the organizational ecology perspective. Several implications of these findings for practitioners are offered, as well as one warning

Evidence-based Management: From Theory to Practice in Health Care

The rise of evidence-based clinical practice in health care has caused some people to start questioning how health care managers and policymakers make decisions, and what role evidence plays in the process. Though managers and policymakers have been quick to encourage clinicians to adopt an evidence-based approach, they have been slower to apply the same ideas to their own practice. Yet, there is evidence that the same problems (of the underuse of effective interventions and the overuse of ineffective ones) are as widespread in health care management as they are in clinical practice. Because there are important differences between the culture, research base, and decision-making processes of clinicians and managers, the ideas of evidence-based practice, while relevant, need to be translated for management rather than simply transferred. The experience of the Center for Health Management Research (CHMR) is used to explore how to bring managers and researchers together and promote the use of evidence in managerial decision-making. However, health care funders, health care organizations, research funders, and academic centers need wider and more concerted action to promote the development of evidence-based managerial practice