Strategizing to Address Healthcare Disparities

Strategizing to Address Healthcare DisparitiesCase studies of health system partnerships and capacity building activities

Professor Lynn Wooten

©Professor Lynn Perry Wooten, June 2007

Ross School of Business, University of Michigan

Agenda

• Introduction of the Research Project

• Framing the Research Issues

• The Case Studies• Lessons Learned &

Reflections



The NIH Roadmap is an integrated vision to deepen our understanding of biology, stimulate interdisciplinary research teams, and reshape clinical research to accelerate medical discovery and improve people's health.



Historical Starting Point

The rate of infant mortality (widely accepted as an accurate index of general health) among Negroes is double that of whites.”

Where Do We Go From Here: Chaos or Community? (Dr. Martin Luther King, 1968)



The Public Health Problem

• According to "Health, United States, 2000," infant mortality rates are more than twice as high for African-Americans.

– Stillbirths– Low Birth Weight

(10% of African-American Infants)

– Pre-term Delivery (20% of African-American Infants)

~ Highest infant mortality rate In the developed world



In the Popular Press (Essence Magazine, November 2005; New York Times; April 22, 2007)

In Turnabout, Infant Deaths Climb in South



“Disparities in the health care delivered to race and ethnic minorities are real and are associated with worst outcomes in many cases, which are unacceptable. The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them.”



'U' study seeks to close gaps in prenatal care (Michigan Daily, October 13, 2004)

• Closing the gap of disparities has become a major goal for many government agencies, researchers, healthcare organizations and community groups. Although in the past decade prenatal care utilization rates have risen, decreasing the overall infant mortality rate, disparities in infant mortality and other perinatal outcomes between various ethnic and socio-economic groups continue to widen. Moreover, researchers have yet to explain all of the differences in birth outcomes experienced by African-Americans compared to other groups.



The Grant’s Goals

• Interdisciplinary research infrastructure to solve public health problems.

• Develop testable hypotheses for new effective approaches to public health problems

• Provide an effective mechanism for communicating research-based information to policy leaders, providers, and patients.

• Three core areas: patients, providers and leaders

• The Research Team (17 departments represented at UM)~ OB/GYN~ Genetics~ Nursing~ Midwifery~ Public Health~ Social Work~ Engineering~ School of Information~ Business~ Sociology~ Anthropology~ Medical History



Thinking Outside the Box: The University of Michigan Roadmap Team’s Interdisciplinary Model





The Organizational Perspective – Research Questions

• How can health care systems change from inertia to action in reducing disparities in patient care? ~ How do health systems frame the problem and its

solutions?~ Why do health system address this problem?~ Who is involved in addressing this problem? Why?~ What are the capacity building and organizational

competencies associated with moving from inertia to action in reducing disparities in patient care?



Research Methodology

• Case Study data collected from a “diverse” set of healthcare organizations~ Direct Observations~ On-site visits~ Interviews~ Archival Data

• Transcribed and Coded into NVivo• Analyzed using a template, grounded

theory approach



Guiding Theories

• Organizational Routines~ Skills and capabilities of organizations and its members; the current

best practice in an industry; enable organizations to cope with complex problems (Nelson & Winter, 1982)

~ An executed capability for repeated performance that has been learned in response to selective pressures (Cohen, 1996).

• Positive Organizing (Wooten, 2004; Dutton & Glynn, 2007)~ Enable organizational resourcefulness~ Enhance organizational strengths and capabilities~ Expand organizational action repertoires~ Collective behavior and relational mechanisms

• Capacity Building~ The building of an infrastructure to efficiently address health

problems (Joffres, et al., 2004)~ The development of core skills, management practices, strategies,

and systems to enhance an organization’s effectiveness, sustainability and ability to fulfill its mission (Connolly, 2001)



Capacity Building in Action:Case Studies of Best Practices

Model created by Connolly & Luka’s for the Fieldstone Alliance



Case Study SitesSite Background InformationCatholic Health System One of the largest Catholic health systems in the

country. The system owns, manages and is affiliated with 20 acute care hospitals and two nursing homes in four states.

City Government A large city that in 2005 a mayoral task force was commissioned to imagine a city that could marshal its resources to address health disparities. Partners for this disparity project include hospitals, the Red Cross, universities, insurance companies, foundations, and the city’s public health department.

County Public Health System

A collaborative effort of public health agencies, corporations, hospitals, a university, and foundations to reduce ethnic and racial health care disparities, with a focus on infant mortality.

National Health Maintenance Organization

An integrated health care delivery system with 8.5 million members, 12,800 physicians and over 150,000 employees. It operates in 9 states with 37 medical centers and 431 medical office buildings.

Southwest Hospital A teaching hospital that provided $409 million in uncompensated care in 2006. Eighty percent of patients are ethnic minorities. Busiest maternity ward in the country.



Conduct 1st

Case Study

Conduct Remaining Case Studies

Select Cases

Develop Theory

Conduct 2nd

Case Study

Design DataCollectionProtocol

•interviews

•observations

•documents

WriteIndividualCase Report

•interviews

•observations

•documents

•define “process” operationally

•define “process” out-comes” (not just ultimate effects)

•use formal data collection techniques



•pattern-match

•policy implications

•pattern-match

•policy implications

•replication

Modify Theory

Develop Policy Implications

Write Cross-CaseReport

Draw Cross-Case Conclusions

• etc. • etc.

The Design of Case Study Research (Yin,1989)



Template Analysis – Thematically analyzing qualitative data

√ Defined a priori theme of capacity building and related codes.

√ Transcribed qualitative data√ Initial coding√ Produced iterative version of templates√ Applied template to case sites√ Created case studies based on capacity

building templates√ Through out the process quality checks

and reflections



Framing: Mission, Vision & Strategy

• Framing organizational action through a mission, vision or strategy bring focus, direction and a guiding paradigm. Frames filter, help with sense-making, and provide a roadmap for taking action (Deal & Bolman, 2003; Ancona et al., 1999: Weick, 1995).

• Framing sends out a message to stakeholders

• Within the case study, organizations frame addressing healthcare disparities as:~ As an integral part

of their mission~ An action-based

public health initiative

~ A business case~ An access to care

issue



Examples of Framing: Mission, Vision & Strategy

• Mission Driven~ “Through our exceptional health care services,

we reveal the healing presence of God” (Catholic Health System)

~ “Our mandate is to furnish medical aid and hospital care to indigent and needy persons residing in the hospital district” (Southwest Hospital)

• The Business/Market Differentiation Case~ Market Positioning -- “We are not a sick plan, but a

health plan” (National HMO)• Action based

~ “Not just another study… but important work being done on the local level to help solve the problem” (City Government)



Example: Framing as A Public Health Problem



Governance, Leadership & Strategic Relationships Through “Partnerships”

• At case studies, City Government and County Health Department leadership and governance emerged through a community health partnership (Weech-Maldonado, Benson & Gamin, 2003); Alexander et al, 2001)

~ Designed to build on strength of local knowledge about health problems and experiences in service delivery

~ Support collaboration between the health care system and the community

~ Partnerships encourage system thinking by taking a population view of health that incorporates disease-based and wellness-based models (Shortell, 1996)

~ Collateral leadership as a super-organizational phenomenon Enables partnerships to tap into diverse skills and resources through a division of roles (Denis, Lamothe, & Langley, 2001)



Community Health Partnerships

• “More than one person or organization is necessary to improve public health … at a minimum academics, health practitioners, and ‘grassroots’ folks.” (County Health Department)

• “Local communities cannot solve this problem alone.This needs to be a priority at every level of government, and embraced by organizations throughout the public health and health care system.” (City Government)

Initiating Organization

Partners

Partners

Partners

Partners

Partners

Partners



Partnering as Knowledge & Resource Brokering

• Knowledge brokering focuses on identifying and bringing together people interested in an issue, people who can help each other develop evidence based solutions (Hargadon, 2002; Canadian Health Service Research Foundation).

• Examples in the cases ~ National HMO convened a conference on topic inviting

competitors; adopted approach from national think tank~ Catholic Health System & County Health Department

brokered best practices and knowledge from other industries.

Initiating Organization

KnowledgeResources

KnowledgeResourcesPartners

or Funders

Partners& Clients



Institutionalization & Organizational Learning of Best Internal Operations Management/Program Delivery

• Organizational learning is a natural consequence of capacity building through collective leadership. Individual leaders not only bring knowledge into the group, but also create knowledge through a learning cycle (Sandmann & Vandenberg, 1995).

• Internal operations and programs emerge from leaders searching for innovative ways to solve a problem, such as by recombining resources, challenging the status quo, or adopting new models (Argyis, 1977).

• This requires the involvement of leaders who possess a skill set to identify relevant information, assimilate it, and apply it toward a new programs or processes (Boal & Hooijberg, 2001).



Internal Operations Management/Program Delivery

Case Site Quality Diversity/Cultural Competencies

Patient Engagement

Data Driven

Catholic Health System

Dominant Focus; Baldridge Metrics

Workforce diversity of health system workers

Community Outreach Programs

Data collection link to TQM and Baldridge Standards

City Government

Workforce diversity of health system workers; Cultural Competencies Training; anti-racism training

Patient Education; Accessing Care; Active participation in treatment

Comprehensive approach to data – race, disease, access, patient satisfaction

County Health Department

Friendly Access Program – Disney’s Approach to quality and customer service

Undoing Racism Patient Education; Access to care: Navigation of Health System; Coordination of Services

Geo-spatial by zip codes. FIMR



Internal Operations Management/Program Delivery (Continued)

Case Site Quality Diversity/Cultural Competencies

Patient Engagement

Data Driven

National HMO Cost Management

HR focus on diversity and cultural competencies

Patient Education & Empowerment; Community Outreach

Targeted healthcare

Southwest Hospital

Standardization of Routines; Hierarchy; Protocol serves as a “medicine cookbook” based on clinical research; Re-engineered the delivery of babies.

Community Outreach

Patient focused as a technique for Managing healthcare



Impact….Defined in different ways



Capacity Building

Organizational Learning

Empowerment & Engagement

Organization A

Organization B

Organization C

Collective Leadership

Through Diverse Partnerships

Reduction in HealthcareDisparities

Access to Healthcare

Quality of Healthcare

Individual & Community Wellbeing

Modeling Partnerships & Capacity Building Activities: From Inertia to Action



Lessons Learned: Health Systems Addressing Health Disparities

• Committed, collective and visionary leadership.

• Framing drives action.• The importance of collecting and

analyzing data.• Organizational Learning• Systematic, targeted, and structured

programs based on best practices and evaluation.



Closing Thought

“If you always do what you’ve always done, you’ll always get what you’ve always got. If you want something you’ve never had, you’ve got to do something you’ve never done.” (A.J. McKnight)

Documents

Strategizing to Address Healthcare Disparities