How personnel diversity and affective bonds affect performance-based financing: a moderator analysis of a difference-in-difference estimator.

To spur improvement in health-care service quality and quantity, performance-based financing (PBF) is an increasingly common policy tool, especially in low- and middle-income countries. This study examines how personnel diversity and affective bonds in primary care clinics affect their ability to improve care quality in PBF arrangements. Leveraging data from a large-scale matched PBF intervention in Tajikistan including 208 primary care clinics, we examined how measures of personnel diversity (position and tenure variety) and affective bonds (mutual support and group pride) were associated with changes in the level and variability of clinical knowledge (diagnostic accuracy of 878 clinical vignettes) and care processes (completion of checklist items in 2485 instances of direct observations). We interacted the explanatory variables with exposure to PBF in cluster-robust, linear regressions to assess how these explanatory variables moderated the PBF treatment's association with clinical knowledge and care process improvements. Providers and facilities with higher group pride exhibited higher care process improvement (greater checklist item completion and lower variability of items completed). Personnel diversity and mutual support showed little significant associations with the outcomes. Organizational features of clinics exposed to PBF may help explain variation in outcomes and warrant further research and intervention in practice to identify and test opportunities to leverage them. Group pride may strengthen clinics' ability to improve care quality in PBF arrangements. Improving health-care facilities' pride may be an affordable and effective way to enhance health-care organization adaptation.

Overcoming walls and voids: Responsive practices that enable frontline workers to feel heard.

BACKGROUND: There is increasing recognition that beyond frontline workers' ability to speak up, their feeling heard is also vital, both for improving work processes and reducing burnout. However, little is known about the conditions under which frontline workers feel heard. PURPOSE: This inductive qualitative study identifies barriers and facilitators to feeling heard among nurses in hospitals. METHODOLOGY: We conducted in-depth semistructured interviews with registered nurses, nurse managers, and nurse practitioners across four hospitals ( N = 24) in a U.S. health system between July 2021 and March 2022. We coded with the aim of developing new theory, generating initial codes by studying fragments of data (lines and segments), examining and refining codes across transcripts, and finally engaging in focused coding across all data collected. FINDINGS: Frontline nurses who spoke up confronted two types of challenges that prevented feeling heard: (a) walls, which describe organizational barriers that lead ideas to be rejected outright (e.g., empty solicitation), and (b) voids, which describe organizational gaps that lead ideas to be lost in the system (e.g., structural mazes). We identified categories of responsive practices that promoted feeling heard over walls (boundary framing, unscripting, priority enhancing) and voids (procedural transparency, identifying a navigator). These practices appeared more effective when conducted collectively over time. CONCLUSION: Both walls and voids can prevent frontline workers from feeling heard, and these barriers may call for distinct managerial practices to address them. Future efforts to measure responsive practices and explore them in broader samples are needed. PRACTICE IMPLICATIONS: Encouraging responsive practices may help ensure that frontline health care workers feel heard.

Joint problem-solving orientation, mutual value recognition, and performance in fluid teamwork environments.

Introduction: Joint problem-solving orientation (JPS) has been identified as a factor that promotes performance in fluid teamwork, but research on this factor remains nascent. This study pushes the frontier of understanding about JPS in fluid teamwork environments by applying the concept to within-organization work and exploring its relationships with performance, mutual value recognition (MVR), and expertise variety (EV). Methods: This is a longitudinal, survey-based field study within a large United States healthcare organization n = 26,319 (2019 response rate = 87%, 2021 response rate = 80%). The analytic sample represents 1,608 departmental units in both years (e.g., intensive care units and emergency departments). We focus on departmental units in distinct locations as the units within which fluid teamwork occurs in the hospital system setting. Within these units, we measure JPS in 2019 and MVR in 2021, and we capture EV by unit using a count of the number of disciplines present. For a performance measure, we draw on the industry-used measurement of perceived care quality and safety. We conduct moderated mediation analysis testing (1) the main effect of JPS on performance, (2) mediation through MVR, and (3) EV as a moderator. Results: Our results affirm a moderated mediation model wherein JPS enhances performance, both directly and through MVR; EV serves as a moderator in the JPS-MVR relationship. JPS positively influences MVR, irrespective of whether EV is high or low. When JPS is lower, greater EV is associated with lower MVR, whereas amid high JPS, greater EV is associated with higher MVR, as compared to lower EV. Discussion: Our findings lend further evidence to the value of JPS in fluid teamwork environments for enabling performance, and we document for the first time its relevance for within-organization work. Our results suggest that one vital pathway for JPS to improve performance is through enhancing recognition of the value that others offer, especially in environments where expertise variety is high.

Psychological Safety as an Enduring Resource Amid Constraints.

Objectives: While psychological safety is recognized as valuable in healthcare, its relationship to resource constraints is not well understood. We investigate whether psychological safety mitigates the negative impact of resource constraints on employees. Methods: Leveraging longitudinal survey data collected from healthcare workers before and during the COVID-19 crisis (N = 27,240), we examine how baseline psychological safety relates to employee burnout and intent to stay over time, and then investigate this relationship relative to resource constraints (i.e., the inadequacy of staffing and tools). Results: Using hierarchical linear models, we find that psychological safety has enduring protective benefits for healthcare workers during periods of stress, and that these benefits mitigate the negative consequences of resource constraints for burnout and turnover intent over time. Conclusion: These findings extend the empirical basis for psychological safety and suggest that investments in building psychological safety can foster employee resilience and organizational commitment, even when resources are strained.

Revisiting organizational culture in healthcare: Heterogeneity as a resource.

Aligning culture to be similar across work units is a common organizational tactic, but its appropriateness for the multidisciplinary context of healthcare is far from certain. Variation in perceptions of culture across large health systems may serve a functional purpose in delivering high quality care and ameliorating job stress; however, past research in healthcare has focused on culture as the average set of values and norms (i.e., cultural content) rather than on (dis)agreement about values and norms among organizational members (i.e., cultural structure). This survey-based study examines both cultural content (averages among individuals) and structure (distances between individuals) in departments of a large U.S. healthcare organization (total sample = 26,314 workers, response rate = 84%). We used linear models to associate four commonly used culture measures with outcome measures (perceived care quality, intent to stay, and manageable job stress). We found substantial heterogeneity in perceptions for multiple culture types. We found curvilinear relationships between heterogeneity for all culture types and outcomes, suggesting that heterogeneity promotes positive outcomes up to a certain point after which the positive effect declines. For research, our findings point to the importance of studying culture in healthcare with greater focus on heterogeneity; for practice, this study highlights how culturally-focused efforts to improve care quality and worker experience in healthcare should be more precise about balancing cultural alignment and heterogeneity.

Speaking Up and Taking Action: Psychological Safety and Joint Problem-Solving Orientation in Safety Improvement.

Healthcare organizations face stubborn challenges in ensuring patient safety and mitigating clinician turnover. This paper aims to advance theory and research on patient safety by elucidating how the role of psychological safety in patient safety can be enhanced with joint problem-solving orientation (JPS). We hypothesized and tested for an interaction between JPS and psychological safety in relation to safety improvement, leveraging longitudinal survey data from a sample of 14,943 patient-facing healthcare workers. We found a moderation effect, in which psychological safety was positively associated with safety improvement, and the relationship was stronger in the presence of JPS. Psychological safety and JPS also interacted positively in predicting clinicians' intent to stay with the organization. For theory and research, our findings point to JPS as a measurable factor that may enhance the value of psychological safety for patient safety improvement-perhaps because voiced concerns about patient safety often require joint problem-solving to produce meaningful change. For practice, our conceptual framework, viewing psychological safety and JPS as complementary factors, can help organizations adopt a more granular approach towards assessing the interpersonal aspect of their safety climate. This will enable organizations to obtain a more nuanced understanding of their safety climate and identify areas for improvement accordingly.

The Human-Technology Continuum.

BACKGROUND AND OBJECTIVES: Managers in health care today face an array of digital technologies that assist or augment certain human tasks. But these technologies are often fraught and present challenges to managers, whose competencies must evolve to keep pace with technological advancements. METHODS: Drawing on theory about technology, work, and organizations, we present a human-technology continuum to facilitate this discussion for managers. Furthermore, we illustrate how managerial competencies are linked to the entire human-technology continuum, rather than to specific technologies, using diabetes management examples. RESULTS: The human-technology continuum indicates that augmentative technologies are layered onto assistive ones in health care settings. This suggests that technological advancements not only enhance but alter managerial competencies. CONCLUSIONS: Digital technology stretches the boundaries of managers' day-to-day work in health care. Therefore, we make the following suggestions so the managers can be responsive to ongoing digital transformations: restructuring work, training the workforce, neutralizing threats, establishing ethical boundaries, and building partnerships.

Practice Site Heterogeneity within and between Medicaid Accountable Care Organizations.

The existing literature has considered accountable care organizations (ACOs) as whole entities, neglecting potentially important variations in the characteristics and experiences of the individual practice sites that comprise them. In this observational cross-sectional study, our aim is to characterize the experience, capacity, and process heterogeneity at the practice site level within and between Medicaid ACOs, drawing on the Massachusetts Medicaid and Children's Health Insurance Program (MassHealth), which launched an ACO reform effort in 2018. We used a 2019 survey of a representative sample of administrators from practice sites participating in Medicaid ACOs in Massachusetts (n = 225). We quantified the clustering of responses by practice site within all 17 Medicaid ACOs in Massachusetts for measures of process change, previous experience with alternative payment models, and changes in the practices' ability to deliver high-quality care. Using multilevel logistic models, we calculated median odds ratios (MORs) and intraclass correlation coefficients (ICCs) to quantify the variation within and between ACOs for each measure. We found greater heterogeneity within the ACOs than between them for all measures, regardless of practice site and ACO characteristics (all ICCs ≤ 0.26). Our research indicates diverse experience with, and capacity for, implementing ACO initiatives across practice sites in Medicaid ACOs. Future research and program design should account for characteristics of practice sites within ACOs.