2011
Measuring Teamwork in Health Care Settings: A Review of Survey Instruments.
Melissa A. Valentine, Ingrid M. Nembhard, Amy Edmondson
Harvard Business School Working Paper, No. 11-116
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To identify, review, and evaluate survey instruments used to assess teamwork, a process critical to delivering quality care, so as to facilitate high quality research on this topic.
Data sources. The ISI Web of Knowledge database, which draws articles from MEDLINE, Social Science Citation Index, and Science Citation Index.
Study design. We conducted a systematic review of articles published before January 2010 to identify survey instruments used to measure teamwork. We evaluated instruments' psychometric properties (e.g., discriminant and content validity) and assessed whether they had been shown to relate to outcomes of interest in peer-reviewed studies.
Data extraction. We identified relevant articles using the search terms team, teamwork, work groups, or collaboration, in combination with survey or questionnaire.
Principal findings. We found 58 scales that measured teamwork; 12 of them have been shown to relate to non-self-report outcomes of interest. Dimensions of teamwork measured differed across scales; however, each of the 12 scales assessed some dimension of the quality of social interactions between members. All but one also assessed some dimension of the quality of task-related interactions. Only three scales met all of the criteria for psychometric validity.
Conclusions. Numerous survey instruments exist to measure teamwork. Few have demonstrated all of the psychometric properties recommended for use, and there is inconsistency in conceptualizations of teamwork. We identify several useful measures and suggest that more research is needed to develop and refine measures of teamwork for reliable use by researchers and practitioners/managers. To read more click here.
Individual Rationality and Participation in Large Scale, Multi-Hospital Kidney Exchange.
Itai. Ashlagi, Alvin E. Roth
NBER Working Paper Series, No. 16720
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As multi-hospital kidney exchange clearinghouses have grown, the set of players has grown from patients and surgeons to include hospitals. Hospitals have the option of enrolling only their hard-to-match patient-donor pairs, while conducting easily arranged exchanges internally. This behavior has already started to be observed. We show that the cost of making it individually rational for hospitals to participate fully is low in almost every large exchange pool (although the worst-case cost is very high), while the cost of failing to guarantee individually rational allocations could be large, in terms of lost transplants. We also identify an incentive compatible mechanism. To read more click here.
Deliberate Learning to Improve Performance in Dynamic Service Settings: Evidence from Hospital Intensive Care Units.
I. M. Nembhard, Anita L. Tucker
Organization Science Journal
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Dynamic service settings-characterized by workers who interact with customers to deliver services in a rapidly changing, uncertain, and complex environment (e.g., hospitals)-play an important role in the economy. Organizational learning studies in these settings have largely investigated autonomous learning via cumulative experience as a strategy for performance improvement. Whether induced learning through the use of deliberate learning activities provides additional performance benefits has been neglected. We argue that the use of deliberate learning activities offers performance benefits beyond those of cumulative experience because these activities counter the learning challenges presented by rapid knowledge growth, uncertainty, and complexity in dynamic settings. We test whether there are additional performance benefits to using deliberate learning activities and whether the effectiveness of these activities depends on interdisciplinary collaboration in the workgroup. We test our hypotheses in a study of 23 hospital neonatal intensive care units (NICUs) involved in a quality improvement collaborative. We find that using deliberate learning activities is associated with better workgroup performance, as measured by NICUs' risk-adjusted mortality rates for 2,159 infant patients, but only after two years. In the shorter term, using these activities is associated with worse performance. By the third year, the positive impact of using deliberate learning activities is similar to the benefit of cumulative experience (18% and 20% reduction in odds of mortality, respectively). Contrary to prediction, interdisciplinary collaboration mediates, rather than moderates, the relationship between using deliberate learning activities and workgroup performance. Thus, our data suggest that using deliberate learning activities fosters interdisciplinary collaboration.
Broadening Focus: Spillovers, Complementarities and Specialization in the Hospital Industry.
Jonathan R. Clark, Robert Huckman
Harvard Business School Working Paper, No. 09-120
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The long-standing argument that focused operations outperform others stands in contrast to claims about the benefits of broader operational scope. The performance benefits of focus are typically attributed to reduced complexity, lower uncertainty, and the development of specialized expertise, while the benefits of greater breadth are linked to the economies of scope achieved by sharing common resources, such as advertising or production capacity, across activities. Within the literature on corporate strategy, this tension between focus and breadth is reconciled by the concept of related diversification (i.e., a firm with multiple operating units, each specializing in distinct but related activities). We consider whether there are similar benefits to related diversification within an operating unit and examine the mechanism that generates these benefits. Using the empirical context of cardiovascular care within hospitals, we first examine the relationship between a hospital's level of specialization in cardiovascular care and the quality of its clinical performance on cardiovascular patients. We find that, on average, focus has a positive effect on quality performance. We then distinguish between positive spillovers and complementarities to examine the following: (1) the extent to which a hospital's specialization in areas related to cardiovascular care directly impacts performance on cardiovascular patients (positive spillovers) and (2) whether the marginal benefit of a hospital's focus in cardiovascular care depends on the degree to which the hospital "co-specializes" in related areas (complementarities). In our setting, we find evidence of such complementarities in specialization. To read more click here.
An Angel Investor With an Agenda.
Regina Herzlinger
Harvard Business School Review Case Study
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Gloria Londono, the owner of a chain of day care centers for the elderly in Spain, is offered 3 million euro by Victor Serna, a wealthy physician-investor. Should she accept Serna's offer or stick to her currently successful strategy of going it alone? To read more click here.
The Importance of Work Context in Organizational Learning from Error.
Lucy H. MacPhail and Amy C. Edmondson
Harvard Business School Working Knowledge
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This paper investigates the range of work contexts in which errors occur in organizations and the implications of this variation for organizational learning. To read more click here.
2010
Measuring Health Outcomes.
Michael Porter
The New England Journal of Medicine
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Achieving good patient health outcomes is the fundamental purpose of healthcare. Measuring, reporting, and comparing outcomes is perhaps the most important step toward unlocking rapid outcome improvement and making good choices about reducing costs. To read more click here.
The Work-Around Culture: Unintended Consequences of Organizational Heroes.
Anita Tucker
Harvard Business School Working Knowledge
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"Work-around cultures" are pervasive in health care. Employees tend to work around obstacles, often feeling like a hero in the process, without solving the underlying problems. The reasons for these cultures are manifold, but they are costly in financial and human terms. To read the executive summary click here.
Management In Healthcare: Why Good Practice Really Matters.
Raffaella Sadun
London School of Economics and Political Science
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This report examines the hypothesis that a company's management practices are likely to have a strong effect on its performance, and that this effect might be stronger than many of the other factors that determine whether a business succeeds. To read the full report click here.
Speaking up constructively: Managerial practices that elicit solutions from front-line employees.
Julia Rose Adler-Milstein, Sara J. Singer, Michael W. Toffel,
Harvard Business School Working Paper, No. 11-005
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Ideas that could enable organizations to improve their operating processes often come from front-line workers who voice concerns and share ideas about how to solve problems. Our study is among the first to develop and empirically test theory about how specific management practices can encourage employees to speak up about problems and to offer suggestions for solving them. We hypothesize that employees are more likely to speak up and offer solutions when organizations launch information campaigns to promote process improvement and when managers engage in process-improvement activities themselves. We test our hypotheses in the health-care context, in which problems are frequent and many organizations use incident-reporting systems to encourage employees to communicate about the operational problems they witness. Using data on nearly 7,500 reported incidents, we find that information campaigns encouraging process improvement promote both speaking up and offering solutions, while managerial engagement in process improvement promotes the latter. Our findings suggest that particular management practices can influence front-line workers' decisions about whether to speak up and that direct managerial engagement can result in their doing so constructively.
From Bench to Board: Gender Differences in University Scientists' Participation in Commercial Science.
Waverly W. Ding, Fiona Murray, Toby E. Stuart,
Harvard Business School Working Paper, No. 11-014
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This paper examines gender differences in the participation of university life science faculty in commercial science. Based on theory and field interviews, we develop hypotheses regarding how scientists' productivity, co-authorship networks, and institutional affiliations have different effects on whether male and female faculty become "academic entrepreneurs." We then statistically examine this framework in a national sample of 6,000 life scientists whose careers span more than 20 years. We find sharp gender differences in participation in for-profit ventures, which we measure as the likelihood of joining the scientific advisory board (SAB) of a biotechnology firm. Compared to men, women life scientists are much less likely to advise for-profit biotechnology companies. We also identify factors that contour this gender difference, including scientists' co-authorship network structure and the level of support for commercial science at their universities. Surprisingly, we find that the (conditional) gender gap is largest among faculty members at the highest status institutions.
Boundary Spanning in a For-profit Research Lab: An Exploration of the Interface Between Commerce and Academe.
Christopher C. Liu, Toby E. Stuart
Harvard Business School Working Paper, No. 11-012
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In innovative industries, private-sector companies increasingly are participants in open communities of science and technology. To participate in the system of exchange in such communities, firms often publicly disclose what would otherwise remain private discoveries. In a quantitative case study of one firm in the biopharmaceutical sector, we explore the consequences of scientific publication-an instance of public disclosure-for a core set of activities within the firm. Specifically, we link publications to human capital management practices, showing that scientists' bonuses and the allocation of managerial attention are tied to individuals' publications. Using a unique electronic mail dataset, we find that researchers within the firm who author publications are much better connected to external (to the company) members of the scientific community. This result directly links publishing to current understandings of absorptive capacity. In an unanticipated finding, however, our analysis raises the possibility that the company's most prolific publishers begin to migrate to the periphery of the intra-firm social network, which may occur because these individuals' strong external relationships induce them to reorient their focus to a community of scientists beyond the firm's boundary.
Managing The New Primary Care: The New Skills That Will Be Needed .
Richard Bohmer
Health Affairs
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This essay argues that primary care physicians should be equipped with the management skills necessary to develop and implement new models of primary care. HBS Professor Richard Bohmer demonstrates that developing new models of primary care will demand a level of managerial expertise that few of today's primary care physicians possess.
Healthcare Reform and its Implications for the U.S. Economy.
Regina Herzlinger
Business Horizons
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U.S. healthcare is currently a poor value proposition in relation to its cost. This must change. Driven by the fundamental forces of financing, consumer preferences, and technology, the U.S. is heading for a profound revolution in healthcare, one that will affect not only the system itself but also the larger U.S. business community. This new healthcare system will create vast opportunities and commensurately large risks for healthcare innovators. The outcomes of the present healthcare reform debate will either liberate or further shackle these innovators. Reforms that depend on governmental controls are more likely to dampen innovation than those achieved through control by consumers, and given the profound ramifications of healthcare reform outcomes, policy makers would be well-advised to harness the forces of consumerism in fashioning reform.
The Economic Crisis and Medical Care Usage, Harvard Business School.
Annamaria Lusardi, Daniel Schneider and Peter Tufano
HBS, Working Knowledge
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In this research, Annamaria Lusardi of Dartmouth College, Daniel Schneider of Princeton University, and Peter Tufano of Harvard Business School find strong evidence that the economic crisis has led to large reductions in the use of routine medical care.
Fixing Health Care on the Front Lines.
Richard Bohmer
Harvard Business Review
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In the United States and around the world, there have been plenty of proposals for curing what ails health care. All of them--new organizational forms, alternative payment systems, and free-market competition--aim to tackle a universal challenge: improving the quality of care and reducing, or at least curbing, its cost. But the reality is that regardless of what happens to the many experiments and reform efforts, including the one in Washington, the basic structure of the health care system in the United States and most other countries will remain in place for the foreseeable future. The only realistic hope for substantially improving care delivery is for the old guard to launch a revolution from within. Existing providers must redesign themselves. They must revamp core clinical processes and the organizational structures, management systems, and cultures supporting them so that they excel at performing three discrete tasks simultaneously: rigorously applying scientifically established best practices for diagnosing and treating diseases that are well understood; employing a trial-and-error process to deal with complicated or poorly understood conditions; and capturing and applying knowledge generated by day-to-day care. Some organizations - such as Intermountain Healthcare, the Cleveland Clinic, and Istituto Clinico Humanitas - have already redesigned themselves in ways that improve quality and lower costs. But no single dominant design exists; each organization has its own environment, structure, and history. More important than the specific designs are the four principles on which they are based: focus on the decisions, tasks, and workflows crucial to optimizing patient care; separate high- and low-variability care; reconfigure the supporting infrastructure and practices to match redesigned clinical processes; and design structure and processes to help organizations learn from their daily work.
Leadership with a Small "l".
Richard Bohmer
British Medical Journal
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What exactly do we mean by leadership in health care? Does it mean to take formal positions in senior leadership teams in hospitals, trusts, health boards, ministries of health, and professional societies-what might be termed leadership with a big "L?" Or does it mean something fine grained and local-leadership with a small "l"?
The Evolution of Science-Based Business: Innovating How We Innovate
Gary Pisano
HBS, Working Knowledge
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This is an essay about organizational innovation and experimentation in the business of science. HBS professor Gary Pisano examines the changing nature of the science-business intersection and describes the emergence of a science-based business as a novel organizational form. He also describes the institutional and organizational challenges created by this convergence.
2009
Limited Choices:
Can you get what you need in a government-run health-insurance market?.
Regina E. Herzlinger
National Review Online
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Virtually all current health-care-reform plans feature a monopoly health-insurance store, operated by federal or state governments, for those who lack employer- or government-sponsored insurance and want to qualify for government subsidies. Advocates claim these monopoly markets will control costs through their purchasing power and enhance price competition by simplifying comparison shopping. When insurers are forced to compete on price, they will prod health-service providers for increased efficiency.
Practicing Medicine in the Age of Facebook.
Sachin H. Jain
New England Journal of Medicine
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In my second week of medical internship, I received a "friend request" on Facebook, the popular social-networking Web site. The name of the requester was familiar: Erica Baxter. Three years earlier, as a medical student, I had participated in the delivery of Ms. Baxter's baby. Now, apparently, she wanted to be back in touch. Despite certain reservations, I clicked "confirm," and Ms. Baxter joined my list of Facebook "friends." I was curious to hear about the progress of her baby girl, but I wondered about the appropriateness of this interaction.
The Shifting Mission of Health Care Delivery Organizations
Richard M.J. Bohmer and Thomas H. Lee
New England Journal of Medicine
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An important transition has begun in payment for health care delivery in the United States: organizations that have long been paid for transactions, such as visits or procedures, are beginning - at least in some markets - to be paid instead for producing outcomes. As physicians and hospital leaders contemplate the implications of new payment models, they realize that the transition will be long, difficult, and messy, with major ramifications for providers.
Are Licensing Markets Local? An Analysis of the Geography of Vertical Licensing Agreements in Bio-Pharmaceuticals.
Juan Alcácer, John Cantwell, and Michelle Gittelman
Presented at NBER's Location of Biopharmaceutical Activity Conference
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As the value chain of the pharmaceutical industry disaggregates, upstream discovery is increasingly carried out by small research-specialized firms while downstream development, testing, and marketing is conducted by global pharmaceutical firms. Licensing plays an important role in this emerging division of labor. Alcácer and his co-authors theorize that, similar to markets for upstream inputs such as scientific knowledge, proximity also may matter for licensing, which they conceptualize as downstream end markets for small biotechnology firms. They examine whether co-location affects the likelihood of vertical licensing transactions between biotechnology firms and global pharmaceutical firms. Discussions with industry executives indicate that large firms search globally for in-licensing opportunities and that licensing transactions should not be sensitive to the geographic locations of the transacting parties. However, an analysis of compounds developed by small biotechnology firms licensed to global pharmaceutical firms suggests that licensing transactions are more likely to occur between firms located in the same geographic area. The results point to the possibility that licensing markets are sensitive to the proximity of the partners and that despite global search processes by multinationals in the pharmaceutical industry, licensing markets are localized.
A Strategy for Health Care Reform - Toward a Value-Based System.
Michael Porter
New England Journal of Medicine
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True reform will require both moving toward universal insurance coverage and restructuring the care delivery system. These two components are profoundly interrelated, and both are essential. Achieving universal coverage is crucial not only for fairness but also to enable a high-value delivery system. When many people lack access to primary and preventive care and cross-subsidies among patients create major inefficiencies, high-value care is difficult to achieve. This is a principal reason why countries with universal insurance have lower health care spending than the United States. However, expanded access without improved value is unsustainable and sure to fail. Even countries with universal coverage are facing rapidly rising costs and serious quality problems; they, too, have a pressing need to restructure delivery.
2008
Does Focus Improve Operational Performance? Lessons from the Management of Clinical Trials
Robert S. Huckman and Darren E. Zinner
Strategic Management Journal
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For over three decades, the benefits of focus have been touted under the guiding principle that
dedicated attention to a small set of linked tasks improves operating performance. Numerous
studies have suggested that the performance of a division, plant, or business unit is improved to
the extent that it remains focused on a narrow range of activities. Others have found similar
benefits associated with focus at the level of the entire firm. A question that has received
less attention, however, is whether focus at the divisional level is complementary with, or a
substitute for, focus at the firm level. We explore this question by considering the performance of
investigative sites in biopharmaceutical clinical trials. First, we establish that firms focusing on
a particular task—at either a divisional or firm level—experience higher output and productivity
with respect to that task than unfocused firms. After controlling for selection, scale, and learning
effects, we find that sites that focus on conducting clinical trials significantly outperform those
that mix trial activity with the provision of traditional patient care. Second, we find evidence that
focus at the divisional level and firm level are substitutes. That is, organizations characterized
by divisional focus alone achieve statistically similar performance to sites that are characterized
by both divisional and firm focus.
Care Platforms: A Basic Building Block For Care Delivery
Richard M.J. Bohmer and David M. Lawrence
Health Affairs
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Without significant operational reform within the nation's health care delivery organizations, new financing models, payment systems, or structures are unlikely to realize their promise. Adapting insights from high-performing companies in other high-risk, high-cost, science- and technology-based industries, we propose the "care platform" as an organizing framework for internal operations in diversified provider organizations to increase the quality, reliability, and efficiency of care delivery. A care platform organizes "care production" around similar work, rather than organs or specialties; integrates standard and custom care processes; and surrounds them with specifically configured information and business systems. Such organizational designs imply new roles for physicians.
Disruptive Innovation In Health Care Delivery: A Framework For Business-Model Innovation
Jason Hwang and Clayton M. Christensen
Health Affairs
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Disruptive innovation has brought affordability and convenience to customers in a variety of industries. However, health care remains expensive and inaccessible to many because of the lack of business-model innovation. This paper explains the theory of disruptive innovation and describes how disruptive technologies must be matched with innovative business models. The authors present a framework for categorizing and developing business models in health care, followed by a discussion of some of the reasons why disruptive innovation in health care delivery has been slow.
2007
The Rise of In-Store Clinics—Threat or Opportunity?
Richard M.J. Bohmer
New England Journal of Medicine
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The recent acquisition by the pharmacy chain CVS of MinuteClinic, a chain of in-store clinics founded in Minnesota, has put this model of primary care delivery back in the spotlight. Although still not widespread, the model is increasing in prevalence and appeals to several stakeholders: payers note that primary care is less expensive when delivered at in-store clinics than when provided in a doctor's office or emergency room, patients value the convenience and low price, entrepreneurs see a profitable business model, and proponents of consumer-driven health care see services that can be paid for out of health savings accounts.
How Physicians Can Change the Future of Health Care
Michael E. Porter and Elizabeth Olmsted Teisberg
The Journal of the American Medical Association
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Today's preoccupation with cost shifting and cost reduction undermines physicians and patients. Instead, health care reform must focus on improving health and health care value for patients. We propose a strategy for reform that is market based but physician led. Physician leadership is essential. Improving the value of health care is something only medical teams can do. The right kind of competition—competition to improve results—will drive dramatic improvement. With such positive-sum competition, patients will receive better care, physicians will be rewarded for excellence, and costs will be contained. Physicians can lead this change and return the practice of medicine to its appropriate focus: enabling health and effective care. Three principles should guide this change: (1) the goal is value for patients, (2) medical practice should be organized around medical conditions and care cycles, and (3) results—risk-adjusted outcomes and costs—must be measured. Following these principles, professional satisfaction will increase, and current pressures on physicians will decrease. If physicians fail to lead these changes, they will inevitably face ever-increasing administrative control of medicine. Improving health and health care value for patients is the only real solution. Value-based competition on results provides a path for reform that recognizes the role of health professionals at the heart of the system.
Health Services for the Poor in Developing Countries: Private vs. Public vs. Private & Public
Tarun Khanna and David M. Bloom
In Business Solutions for the Global Poor: Creating Social and Economic Value. San Francisco: Jossey-Bass, 2007.
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In much of the developing world, poor health is a major impediment to both quality of life and economic development. The poor are particularly vulnerable to the economic impacts of ill health, as they lack the savings to pay for prevention and treatment, and often rely on their own physical labor for their livelihoods. As a result, long-term illnesses strip families of income and assets. At the same time, the public health systems of most developing countries tend to focus their modest resources on treatment rather than prevention, and often give higher priority to diseases that afflict the wealthy rather than the poor. This paper discusses ways of addressing these obstacles and meeting the need for healthcare in developing countries. It looks at different types of health interventions and the different actors (government, for-profit companies and non-profits) involved and then discusses three major health problems—heart disease, HIV/AIDS, and childhood illnesses—to show the different levels of private sector involvement in health. We focus in particular on partnerships between public and private sector organizations and on how such partnerships can be most effective.
2006
The effects of cardiac specialty hospitals on the cost and quality of medical care
Jason R. Barro, Robert S. Huckman, Daniel P. Kessler
Journal of Health Economics
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The recent rise of specialty hospitals — typically for-profit firms that are at least partially owned by
physicians — has led to substantial debate about their effects on the cost and quality of care. Advocates of
specialty hospitals claim they improve quality and lower cost; critics contend they concentrate on providing
profitable procedures and attracting relatively healthy patients, leaving (predominantly nonprofit) general
hospitals with a less-remunerative, sicker patient population. We find support for both sides of this debate.
Markets experiencing entry by a cardiac specialty hospital have lower spending for cardiac care without
significantly worse clinical outcomes. In markets with a specialty hospital, however, specialty hospitals tend
to attract healthier patients and provide higher levels of intensive procedures than general hospitals.
