Using resource dependency theory to measure the environment in health care organizational studies: a systematic review of the literature.

BACKGROUND: Studies using the resource dependency theory (RDT) perspective commonly focus on one or more of the following environmental dimensions: munificence, dynamism, and complexity. To date, no one has reviewed the use of this theory in the health care management literature and there exists no consensus on how to operationalize the market environment in health care settings. PURPOSE: The purpose of this review is to examine and summarize the ways in which RDT has been applied in empirical studies of the external environments of health care organizations. In so doing, we identify gaps in the literature and examine the extent to which previous empirical findings aligned with hypothesized relationships based on RDT. METHODOLOGY: We conducted a systematic review of the peer-reviewed literature using a bibliographic search of PubMed and ABI/Inform databases. To identify all health care studies that incorporated the RDT perspective, the words "healthcare" or "health care" were searched in combination with any of the following words: resource dependency theory, uncertainty perspective, environment, munificence, dynamism, and complexity. We also performed a hand search of the reference lists of all manuscripts identified in the initial search to identify additional articles. FINDINGS: Twenty studies were included in this review. Wide variability existed in the number of variables used to measure the environment, the environmental constructs measured, and the specific variables used to operationalizethe environmental constructs. Of the 198 tests examining the relationship between environmental variables and the outcome of interest, 26.8% resulted in findings that supported the RDT-predicted hypotheses. PRACTICE IMPLICATIONS: The RDT literature is limited to studies of hospitals, nursing homes, and medical practices. There is little consensus on how to measure or operationalize the environment in these studies. No previous studies have measured the environment for other health care settings such as ambulatory surgery centers, public health departments, or assisted living facilities.

Interprofessional academic health center leadership development: the case of the University of Alabama at Birmingham's Healthcare Leadership Academy.

AIM: The study describes the genesis of the University of Alabama at Birmingham's Healthcare Leadership Academy (HLA), highlights the HLA's outcomes, discloses how the HLA has changed, and delineates future directions for academic health center (AHC) interprofessional leadership training. BACKGROUND: While interprofessional training is recognized as an important component of the professional education for health professionals, AHCs have not focused on interprofessional leadership training to prepare future AHC leaders. As professional bureaucracies, AHCs require leadership distributed across different professions; these leaders not only should be technical experts, but also skilled at interprofessional teamwork and collaborative governance. METHODS: The HLA is examined using the case method, which is supplemented with a descriptive analysis of program evaluation data and outcomes. RESULTS: The HLA has created a networked community of AHC leaders; the HLA's interprofessional team projects foster innovative problem solving. CONCLUSIONS: Interprofessional leadership training expands individuals' networks and has multiple organizational benefits.

A longitudinal model of the dynamics between HMOs' consumer-friendliness and preventive health care utilization.

This study aims at replicating and extending Xiao and Savage's (2008) research to understand the multidimensional aspect of HMOs distinguished by HMOs' consumer-friendliness, and their relationship to consumers' preventive care utilization. This study develops a dynamic model to consider both concurrent and time lagging effects of HMOs' consumer-friendliness. Our data analysis discloses similar relationship patterns as revealed by Xiao and Savage. Additionally, our findings reveal the time-series changes of the influence of HMOs' consumer-friendliness that either the effects of early experienced HMOs' consumer-friendliness wear out totally or HMOs' consumer-friendly characteristics on the concurrent term contain most of the explanatory power.

Environmental factors and quality improvement in county and local health departments.

OBJECTIVE: On the basis of resource dependency theory and the uncertainty principle, this study examines the relationship between the local public health market environment and the use of quality improvement (QI) strategies in local health departments. DESIGN: This cross-sectional study uses secondary data from the 2008 National Association of County & City Health Officials profile study, the Health Resources and Services Administration's Area Resource File, and the County Health Rankings 2010 data set. SETTING AND PARTICIPANTS: US local health departments. MAIN OUTCOME MEASURES: Seven binary dependent variables that represented the use of QI processes or QI training within local health departments were used. Eight independent variables were identified and operationalized to measure the constructs of munificence, dynamism, and complexity for the local public health market environment. Bivariate and multivariate regression analyses were used. RESULTS: Two of the 3 munificence variables were positively associated with QI, as predicted. These included percentage of zip codes with healthy food outlets (ß = +.016, P < .05) and the number of primary care physicians per capita (ß = +1.327, P < .05). Two of the 3 measures of complexity were, as predicted, negatively associated with indicators of QI. These included smoking prevalence (ß = -.118, P < .05) and obesity rates (ß = -.081, P < .10). With respect to dynamism, 1 variable (change in population size over a 5-year period) was unexpectedly, positively related to QI (ß = +.118, P < .10 and ß = +0.235, P < .05). CONCLUSIONS: Overall findings provide moderate support for the use of resource dependency theory and the uncertainty perspective to understand the influence of the external environment on QI within the local public health setting. Future research should examine other ways of operationalizing these environmental constructs to examine the relationship between the environment and other elements of public health practice.

Rework and workarounds in nurse medication administration process: implications for work processes and patient safety.

BACKGROUND: Health care organizations have redesigned existing and implemented new work processes intended to improve patient safety. As a consequence of these process changes, there are now intentionally designed "blocks" or barriers that limit how specific work actions, such as ordering and administering medication, are to be carried out. Health care professionals encountering these designed barriers can choose to either follow the new process, engage in workarounds to get past the block, or potentially repeat work (rework). Unfortunately, these workarounds and rework may lead to other safety concerns. PURPOSE: The aim of this study was to examine rework and workarounds in hospital medication administration processes. METHODOLOGY/APPROACH: Observations and semistructured interviews were conducted with 58 nurses from four hospital intensive care units focusing on the medication administration process. Using the constant comparative method, we analyzed the observation and interview data to develop themes regarding rework and workarounds. From this analysis, we developed an integrated process map of the medication administration process depicting blocks. FINDINGS: A total of 12 blocks were reported by the participants. Based on the analysis, we categorized them as related to information exchange, information entry, and internal supply chain issues. Whereas information exchange and entry blocks tended to lead to rework, internal supply chain issues were more likely to lead to workarounds. PRACTICE IMPLICATIONS: A decentralized pharmacist on the unit may reduce work flow blocks (and, thus, workarounds and rework). Work process redesign may further address the problems of workarounds and rework.

The influence of environmental and organizational factors on hospitals' clinical IT sophistication.

The present study examines the separate and combined effects of environmental and organizational variables on hospitals' clinical IT sophistication in a multivariate framework. The analyses focused on two distinct but related questions. First, in the context of the bivariate hypotheses, what is the relative significance empirically of each of the environmental and organizational classes of variables? And second, within classes and on an overall basis, which specific variables make the largest contribution to explained variance in the dependent variable hospitals' clinical IT sophistication when all other variables are held constant? Data collected from 99 Texas hospitals are analyzed to assess the effects of the antecedent variables both within and across classes. Our findings suggest the bigger contribution of environmental antecedents to the level of clinical IT sophistication in hospitals, compared to that of organizational antecedents. We end by discussing the limitations and implications of the study.

Predicting Nursing Home Financial Distress Using the Altman Z-Score.

This article uses a modified Altman Z-score to predict financial distress within the nursing home industry. The modified Altman Z-score model uses multiple discriminant analysis (MDA) to examine multiple financial ratios simultaneously to assess a firm's financial distress. This study utilized data from Medicare Cost Reports, LTCFocus, and the Area Resource File. Our sample consisted of 167 268 nursing home-year observations, or an average of 10 454 facilities per year, in the United States from 2000 through 2015. The independent financial variables, liquidity, profitability, efficiency, and net worth were entered stepwise into the MDA model. All of the financial variables, with the exception of net worth, significantly contributed to the discriminating power of the model. K-means clustering was used to classify the latent variable into 3 categorical groups: distressed, risk-of-financial distress, and healthy. These findings will provide policy makers and practitioners another tool to identify nursing homes that are at risk of financial distress.

HMOs' consumer-friendliness and preventive health care utilization: exploratory findings from the 2002 Medical Expenditure Panel Survey.

Research should move beyond the simple dichotomy between HMO and non-HMO care provision, and embrace the multidimensional aspects of HMOs. Doing so, we argue, helps address the issue of HMO performance. We used a consumer-centered approach to distinguish multiform HMOs and asked the questions, "Do HMOs differ in their consumer-friendly characteristics?" and if so, "Are these characteristics associated with different preventive health care utilization outcomes?" In this exploratory study, the consumer-friendly characteristics of both Medicaid HMOs and private HMOs were examined in relationship to consumers' utilization of preventive care services. HMOs did differ in their consumer-friendly characteristics, and some of these characteristics were significantly associated with the utilization of preventive care services.

The Role of Individual and Collective Mindfulness in Promoting Occupational Safety in Health Care.

Although the importance of safety regulations is highly emphasized in hospitals, nurses frequently work around, or intentionally bypass, safety regulations. We argue that work-arounds occur because adhering to safety regulations usually requires more time and work process design often lacks complementarity with safety regulations. Our main proposition is that mindfulness is associated with a decrease in occupational safety failures through a decrease in work-arounds. First, we propose that individual mindfulness may prevent the depletion of motivational resources caused by worrying about the consequences of time lost when adhering to safety regulations. Second, we argue that collective mindfulness may provide nursing teams with a cognitive infrastructure that facilitates the detection and adaptation of work processes. The results of a multilevel analysis of 580 survey responses from nurses are consistent with our propositions. Our multilevel analytic approach enables us to account for the unique variance in work-arounds that individual and collective mindfulness explain.

Beyond rankings: using cognitive mapping to understand what health care journals represent.

Studies of journal ratings are often controversial. Indices, including impact factors, acceptance rates, expert opinions, and ratings of knowledge, relevance, and quality have been used to organize journals hierarchically. While there may be some validity in consensus rankings, it is unclear what purpose is actually achieved by these endeavors. Impact factors probably help researchers identify authoritative journals, but other rankings likely indicate little more than institutionalized perceptions of prestige. Ranking schema used to derive evaluative judgments do not provide information about the organization of journals from the perspective of substantive content, emphasis, or targeted audience. A cognitive mapping approach that examines how health care management faculty members represent their perceptions of North American health care-oriented journals is presented as an alternative. A card-sort task and importance rating scale was mailed to faculty of North American health management programs who participated in a previous journal ranking study conducted by the authors. Completed assessments were returned from 147 respondents for a response rate of 39%. Multidimensional scaling and hierarchical cluster analyses of data provided a three-dimensional, seven cluster map that illustrates the perceived similarities of journals. Dimension I contrasts Applied Management Practice with Health Policy journals. Dimension II contrasts specific domain with broad-based research journals. Dimension III contrasts finance-oriented with delivery-oriented journals. The seven clusters of perceptually similar journals were weighted in terms of respondent defined importance ascribed to each journal within a cluster. This framework supplements ratings by providing insight about how journals are cognitively organized by scholars.

International "best practices" in health care: the roles of context and innovation.

PURPOSE: Explores recent approaches to international best practices and how they relate to context and innovation in health services. DESIGN/METHODOLOGY/APPROACH: Critical review of existing research on best practices and how they created, diffused, and translate in the international setting. FINDINGS: Best practices are widely used and discussed, but processes by which they are developed and diffused across international settings are not well understood. RESEARCH IMPLICATIONS: Further research is needed on innovation and dissemination of best practices internationally. ORIGINALITY/VALUE: This commentary points out directions for future research on innovation and diffusion of best practices, particularly in the international setting.

Inernational research in health care management: its need in the 21st century, methodological challenges, ethical issues, pitfalls, and practicalities.

PURPOSE: This commentary argues in favor of international research in the 21st century. Advances in technology, science, communication, transport, and infrastructure have transformed the world into a global village. Industries have increasingly adopted globalization strategies. Likewise, the health sector is more internationalized whereby comparisons between diverse health systems, international best practices, international benchmarking, cross-border health care, and cross-cultural issues have become important subjects in the health care literature. The focus has now turned to international, collaborative, cross-national, and cross-cultural research, which is by far more demanding than domestic studies. In this commentary, we explore the methodological challenges, ethical issues, pitfalls, and practicalities within international research and offer possible solutions to address them. DESIGN/METHODOLOGY/APPROACH: The commentary synthesizes contributions from four scholars in the field of health care management, who came together during the annual meeting of the Academy of Management to discuss with members of the Health Care Management Division the challenges of international research. FINDINGS: International research is worth pursuing; however, it calls for scholarly attention to key methodological and ethical issues for its success. ORIGINALITY/VALUE: This commentary addresses salient issues pertaining to international research in one comprehensive account.

Rating outlets for health care management research: an update and extension.

The ongoing discussion of our intellectual community requires that occasionally an effort be made to value the outlets for our research and erect guideposts for our colleagues to signal important contributions to our discipline. This study extends previous work through a survey sent to 1,254 academics involved in health care management research that asked them to rate 54 potential outlets for their research. Ratings were made on journal knowledge, quality, and relevance. Two survey waves resulted in 389 responses (adjusted response rate 37.8 percent). For quality and relevance, journal rankings were separated into A, B, and C categories. The results correlated strongly with the two previous studies in this area. This study extends previous research and provides a categorization of journals on knowledge, quality, and relevance that may assist in faculty performance evaluation and identification of appropriate outlets for manuscripts.

Impact of patient feedback on residents' handheld computer use: a multi-site study.

Handheld computers are being proposed as a resource for ambulatory care, yet physician reluctance to use the devices in the presence of patients is reported to be a barrier to optimal use. This study examined patient attitudes toward the use of handheld computers and the impact of those attitudes on the physicians' use of the handheld computers in the patient care setting. Most patients hold favorable attitudes toward physician use of handheld computers. Providing these data to physicians, however, did not uniformly lead to significant increases in handheld use in the presence of the patient. More understanding of the factors that influence behavior change and methods that will decrease barriers to the use of handhelds is needed

Value-chain analysis of a rural health program: toward understanding the cost benefit of telemedicine applications.

While telemedicine's clinical effectiveness and educational benefits are accepted, its cost-effectiveness is controversial. This study focuses on telemedicine's cost-effectiveness from a provider's perspective. Reviews of the cost-effectiveness literature in telemedicine are critical of past studies' (a) methodological and analytical weaknesses; (b) focus on answering "Can we do this?" rather than "Should we do this?"; and (c) emphasis on patient benefits. Value chain analysis examines structural and executional cost drivers; a self-sustaining business model balances the cost and value associated with each telemedicine activity. We illustrate this analysis in a rural health program, examining teleradiography and telerehabilitation.

Responding to a crisis: a stakeholder analysis of community health organizations.

On May 11, 2001, the Bureau of Primary Health Care notified West Alabama Health Services, doing business as Family HealthCare of Alabama, that it was terminating $6 million in grants due to non-compliance and amid allegations of financial mismanagement and fraud. West Alabama Health Services, a not-for-profit organization, operated 19 community health centers that provided preventive and primary care services for 17 counties in Alabama. This disruption of health services engendered considerable stakeholder debate. Within this context, the authors examine how a small, newly established rural health center and a well-established, federally qualified community health center responded to this crisis. The authors use a stakeholder analysis framework to highlight how key relationships with stakeholders may change with the perceived credibility of the organizational leaders and the legitimacy of their actions.

Safety leadership: extending workplace safety climate best practices across health care workforces.

PURPOSE: Hospitals within the United States consistently have injury rates that are over twice the national employee injury rate. Hospital safety studies typically investigate care providers rather than support service employees. Compounding the lack of evidence for this understudied population is the scant evidence that is available to examine the relationship of support service employees'perceptions of safety and work-related injuries. To examine this phenomenon, the purpose of this study was to investigate support service employees' perceptions of safety leadership and social support as well as the relationship of safety perception to levels of reported injuries. DESIGN/METHODOLOGY/APPROACH: A nonexperimental survey was conducted with the data collected from hospital support service employees (n = 1,272) and examined. (1) relationships between safety leadership (supervisor and organization) and individual and unit safety perceptions; (2) the moderating effect of social support (supervisor and coworker) on individual and unit safety perceptions; and (3) the relationship of safety perception to reported injury rates. The survey items in this study were based on the items from the AHRQ Patient Safety Culture Survey and the U.S. National Health Care Surveys. FINDINGS: Safety leadership (supervisor and organization) was found to be positively related to individual safety perceptions and unit safety grade as was supervisor and coworker support. Coworker support was found to positively moderate the following relationships: supervisor safety leadership and safety perceptions, supervisor safety leadership and unit safety grade, and senior management safety leadership and safety perceptions. Positive employee safety perceptions were found to have a significant relationship with lower reported injury rates. VALUE/ORIGINALITY: These findings suggest that safety leadership from supervisors and senior management as well as coworker support has positive implications for support service employees' perceptions of safety, which, in turn, are negatively related to lower odds of reporting injuries.

Living up to safety values in health care: the effect of leader behavioral integrity on occupational safety.

While previous research has identified that leaders' safety expectations and safety actions are important in fostering occupational safety, research has yet to demonstrate the importance of leader alignment between safety expectations and actions for improving occupational safety. We build on safety climate literature and theory on behavioral integrity to better understand the relationship between the leader's behavioral integrity regarding safety and work-related injuries. In a time-lagged study of 658 nurses, we find that behavioral integrity for high safety values is positively associated with greater reporting of fewer and less severe occupational injuries. The effects of behavioral integrity regarding safety can be better understood through the mediating mechanisms of safety compliance and psychological safety toward one's supervisor. We discuss the implications of our findings for future research on safety climate.

A Dutch and American commentary on IT in health care: roundtable discussions on IT and innovations in health care.

PURPOSE: This chapter reports on experts' perspectives on health information technology (HIT) and how it may be used to improve health care quality and to lower health care costs. DESIGN/METHODOLOGY/APPROACH: Two roundtables were convened that focused on how to best use HIT to improve the quality of health care while ensuring it is accessible and affordable. Participants drew upon lessons learned in the Netherlands, the United States, and other countries. FINDINGS: The first roundtable focused on the use of (1) electronic health records (EHRs) by health care providers, (2) cloud computing for EHRs and health portals for consumers, and (3) data registries and networks for public health surveillance. The second roundtable highlighted (1) the rapid growth of personalized medicine, (2) the corresponding growth and sophistication of bioinformatics and analytics, (3) the increasing presence of mobile HIT, and (4) the disruptive changes in the institutional structures of biomedical research and development. PRACTICAL IMPLICATIONS: Governmental sponsorship of small pilot projects to solve practicable health system problems would encourage HIT innovation among key stakeholders. However, large-scale HIT solutions developed through small pilot projects--should be pursued through public-private partnerships. At the same time, governments should speed up legislative and regulatory procedures to encourage adoption of cost-effective HIT innovations. SOCIAL IMPLICATIONS: Mobile HIT and social media are capable of fostering disease prevention and encouraging personal responsibility for improving or stabilizing chronic diseases. ORIGINALITY/VALUE: Both health services researchers and policy makers should find this chapter of value since it highlights trends in HIT and addresses how health care quality may be improved while costs are contained.

Behavioral integrity for safety, priority of safety, psychological safety, and patient safety: a team-level study.

This article clarifies how leader behavioral integrity for safety helps solve follower's double bind between adhering to safety protocols and speaking up about mistakes against protocols. Path modeling of survey data in 54 nursing teams showed that head nurse behavioral integrity for safety positively relates to both team priority of safety and psychological safety. In turn, team priority of safety and team psychological safety were, respectively, negatively and positively related with the number of treatment errors that were reported to head nurses. We further demonstrated an interaction effect between team priority of safety and psychological safety on reported errors such that the relationship between team priority of safety and the number of errors was stronger for higher levels of team psychological safety. Finally, we showed that both team priority of safety and team psychological safety mediated the relationship between leader behavioral integrity for safety and reported treatment errors. These results suggest that although adhering to safety protocols and admitting mistakes against those protocols show opposite relations to reported treatment errors, both are important to improving patient safety and both are fostered by leaders who walk their safety talk.