The Roles of Senior Management in Quality Improvement Efforts: What Are
the Key Components?
Elizabeth H. Bradley, Ph.D., associate professor, Department of Epidemiology
and Public Health, Yale School of Medicine, New Haven, Connecticut; Eric
S. Holmboe, M.D., associate professor, Department of Medicine, Yale University
School of Medicine; Jennifer A. Mattera, assistant director, Yale-New
Haven Hospital Center for Outcomes Research and Evaluation, New Haven,
Connecticut; Sarah A. Roumanis, R.N., project coordinator, Yale-New Haven
Hospital; Martha J. Radford, M.D., system director, Clinical Quality,
Yale-New Haven Health System, and associate professor of medicine, Section
of Cardiovascular Medicine, Yale University School of Medicine; and Harlan
M. Krumholz, M.D., professor of medicine and epidemiology and public health,
Department of Medicine and Epidemiology and Public Health, Yale University
School of Medicine
attention directed at quality problems and medical errors in healthcare
organizations, the ability of senior management to promote and sustain
effective quality improvement efforts is paramount to their organizational
success. We sought to define the key roles and activities that comprise
senior managers' involvement in improvement efforts directed at physicians'
prescription of beta-blockers after acute myocardial infarction (AMI).
We also developed a taxonomy to organize the diverse roles and activities
of managers in quality improvement efforts and proposed key elements that
might be most central to successful improvement efforts.
Results are based on a qualitative study of 8 hospitals across the country
and included in-depth interviews with 45 clinical and administrative staff
from these hospitals. The findings help identify a checklist that senior
managers may use to assess their own and others' participation in quality
improvement efforts in their institutions. By reinforcing their current
involvement or by identifying potential gaps in their involvement in quality
improvement efforts, practitioners may enhance their effectiveness in
promoting and sustaining quality in clinical care.
THE LONG-TERM COSTS OF CAREER INTERRUPTIONS
Patricia G. Ketsche, M.B.A., Ph.D., assistant professor, Institute of
Health Administration, JMR College of Business, Georgia State University,
Atlanta, Georgia, and Lisette Branscomb, M.B.A., senior research associate,
Institute of Health Administration, JMR College of Business, Georgia State
is based on a study that analyzed the long-term salary implications of
career choices made by healthcare administrators. The study used a cohort
of graduates from a single health administration program; these individuals
had comparable levels of human capital at the outset of their careers.
We estimated the effect of periods of part-time employment and job interruptions-voluntary
and involuntary-on long-term salary progression. We also estimated the
impact of other career choices, such as membership in a professional organization
or the decision to relocate. After controlling for these choices, we estimated
the residual effect of gender on salary. We found that voluntary interruptions
had a greater effect on long-term salary growth than did involuntary interruptions
of the same length or periods of part-time employment.
Individuals evaluating options for balancing career and family constraints
should understand the long-term cost of choosing a career interruption
rather than part-time employment during periods of heightened responsibilities
outside the workplace. Healthcare administrators should also be educated
about the positive association between professional memberships and career
advancement to make informed decisions about participation in such organizations.
Surprisingly, after controlling for all choice variables, gender had no
measurable effect on long-term salary growth. Half of those who indicated
a voluntary interruption for dependent care reasons preferred part-time
or flexible-hour work if it had been available. These results suggest
a pool of healthcare administrators who might compete for positions if
more part-time opportunities were available.
UNDERSTANDING ORGANIZATIONAL DESIGNS OF PRIMARY CARE PRACTICES
Alfred F. Tallia, M.D., associate professor and vice chair, Department
of Family Medicine, University of Medicine and Dentistry of New Jersey,
Robert Wood Johnson Medical School, New Brunswick, New Jersey; Kurt C.
Stange, M.D., Ph.D., professor, Departments of Family Medicine, Epidemiology
and Biostatistics, and Sociology, Case Western Reserve University, Cleveland,
Ohio; Reuben R. McDaniel, Jr., Ed.D., Charles and Elizabeth Prothro Regents
Chair in Health Care Management and professor, Department of Management
Sciences and Information Systems, The University of Texas at Austin; Virginia
A. Aita, Ph.D., assistant professor, Department of Preventive and Societal
Medicine, University of Nebraska Medical Center, Omaha; William L. Miller,
M.D., chair, Department of Family Practice, Lehigh Valley Hospital and
Health Network, Allentown, Pennsylvania; and Benjamin F. Crabtree, Ph.D.,
professor and research director, Department of Family Medicine, University
of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School
past decade, many hospitals experienced difficulty integrating primary
care practices into their health systems. We hypothesized that this difficulty
may be, in part, a result of limited understanding of practice organizational
designs. The structure and function of practices have not been well studied.
In this article, we answer the following questions: Are practices all
the same, or do variations in their organizational design exist? Do hospital
designs predict the designs of affiliated practices? If variation exists,
what are the management implications?
Eighteen family practices, including nine affiliated with five separate
hospital systems, were studied using an in-depth comparative case study
design. A content analysis of the rich descriptive data from these cases
indicates that a great variety exists in the organizational design of
primary care practices, and this variety appears to be influenced by the
initial conditions under which the practice was organized. Hospital system
design in and of itself did not predict the design of affiliated practices.
In fact, both affiliated and independent practices exhibited a range of
design characteristics, some of which did not fit traditional models.
Hospital systems that allowed greater flexibility of practice organizational
designs were more effective at integrating and managing practices. Practice
response to environmental change was greater when practice autonomy was
These findings suggest that a science of practice organizational design
separate from that of hospitals is needed to help explain the success
and failure of practices within health systems and to provide information
for planning practice change.