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This paper introduces the construct of leader inclusiveness-words and deeds exhibited by leaders that invite and appreciate others' contributions. We propose that leader inclusiveness helps cross-disciplinary teams overcome the inhibiting effects of status differences, allowing members to collaborate in process improvement. The existence of a professional hierarchy in medicine and the differential status accorded to those in different disciplines is well established in the health care literature, as is the need for quality improvement. We build on this foundation to suggest that profession-derived status is positively associated with psychological safety (H1)-a key antecedent of speaking up and learning behavior-in health care teams. We hypothesize that this effect varies across teams (H2), and furthermore, that leader inclusiveness predicts psychological safety (H3) and moderates the relationship between status and psychological safety (H4). Finally, we suggest psychological safety predicts engagement in quality improvement work (H5) and mediates the relationship between leader inclusiveness and engagement (H6). Survey data collected in 23 neonatal intensive care units involved in quality improvement projects support our hypotheses. These results provide insight into antecedents of and strategies for fostering improvement efforts in health care and other sectors in which cross-disciplinary teams engage in collaborative learning to improve products or services.

Background Despite decades of efforts to improve quality of health care, poor performance persists in many aspects of care. Less than 1% of the enormous national investment in medical research is focused on improving health care delivery. Furthermore, when effective innovations in clinical care are discovered, uptake of these innovations is often delayed and incomplete. In this paper, we build on the established principle of 'positive deviance' to propose an approach to identifying practices that improve health care quality. Methods We synthesize existing literature on positive deviance, describe major alternative approaches, propose benefits and limitations of a positive deviance approach for research directed toward improving quality of health care, and describe an application of this approach in improving hospital care for patients with acute myocardial infarction. Results The positive deviance approach, as adapted for use in health care, presumes that the knowledge about 'what works' is available in existing organizations that demonstrate consistently exceptional performance. Steps in this approach: identify 'positive deviants,' i.e ., organizations that consistently demonstrate exceptionally high performance in the area of interest ( e.g ., proper medication use, timeliness of care); study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance; test hypotheses statistically in larger, representative samples of organizations; and work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practices. The approach is particularly appropriate in situations where organizations can be ranked reliably based on valid performance measures, where there is substantial natural variation in performance within an industry, when openness about practices to achieve exceptional performance exists, and where there is an engaged constituency to promote uptake of discovered practices. Conclusion The identification and examination of health care organizations that demonstrate positive deviance provides an opportunity to characterize and disseminate strategies for improving quality.

Background Recognition that coordination among healthcare providers is associated with better quality of care and lower costs has increased interest in interventions designed to improve care coordination. One intervention is to add care coordination to nurses’ role in a formal way. Little is known about effects of this approach, which tends to be pursued by small organizations and those in lower-resource settings. We assessed effects of this approach on care experiences of high-risk patients (those most in need of care coordination) and clinician teamwork during the first 6 months of use. Methods We conducted a quasi-experimental study using a clustered, controlled pre-post design. Changes in staff and patient experiences at six community health center practice locations that introduced the added-role approach for high-risk patients were compared to changes in six locations without the program in the same health system. In the pre-period (6 months before intervention training) and post-period (about 6 months after intervention launch, following 3 months of training), we surveyed clinical staff ( N  = 171) and program-qualifying patients (3007 pre-period; 2101 post-period, including 113 who were enrolled during the program’s first 6 months). Difference-in-differences models examined study outcomes: patient reports about care experiences and clinician-reported teamwork. We assessed frequency of patient office visits to validate access and implementation, and contextual factors (training, resources, and compatibility with other work) that might explain results. Results Patient care experiences across all high-risk patients did not improve significantly ( p  > 0.05). They improved somewhat for program enrollees, 5% above baseline reports ( p  = 0.07). Staff-perceived teamwork did not change significantly ( p  = 0.12). Office visits increased significantly for enrolled patients ( p  < 0.001), affirming program implementation (greater accessing of care). Contextual factors were not reported as problematic, except that 41% of nurses reported incompatibility between care coordination and other job demands. Over 75% of nurses reported adequate training and resources. Conclusions There were some positive effects of adding care coordination to nurses’ role within 6 months of implementation, suggesting value in this improvement strategy. Addressing compatibility between coordination and other job demands is important when implementing this approach to coordination.

BACKGROUND:Teamwork in health care settings is widely recognized as an important factor in providing high-quality patient care. However, the behaviors that comprise effective teamwork, the organizational factors that support teamwork, and the relationship between teamwork and patient outcomes remain empirical questions in need of rigorous study. OBJECTIVE:To identify and review survey instruments used to assess dimensions of teamwork so as to facilitate high-quality research on this topic. RESEARCH DESIGN:We conducted a systematic review of articles published before September 2012 to identify survey instruments used to measure teamwork and to assess their conceptual content, psychometric validity, and relationships to outcomes of interest. We searched the ISI Web of Knowledge database, and identified relevant articles using the search terms team, teamwork, or collaboration in combination with survey, scale, measure, or questionnaire. RESULTS:We found 39 surveys that measured teamwork. Surveys assessed different dimensions of teamwork. The most commonly assessed dimensions were communication, coordination, and respect. Of the 39 surveys, 10 met all of the criteria for psychometric validity, and 14 showed significant relationships to nonself-report outcomes. CONCLUSIONS:Evidence of psychometric validity is lacking for many teamwork survey instruments. However, several psychometrically valid instruments are available. Researchers aiming to advance research on teamwork in health care should consider using or adapting one of these instruments before creating a new one. Because instruments vary considerably in the behavioral processes and emergent states of teamwork that they capture, researchers must carefully evaluate the conceptual consistency between instrument, research question, and context.

Despite international recognition of the importance of healthcare management in the development of high-performing systems, the path by which countries may develop and sustain a professional healthcare management workforce has not been articulated. Accordingly, we sought to identify a set of common themes in the establishment of a professional workforce of healthcare managers in low- and middle-income country (LMIC) settings using a descriptive case study approach. We draw on a historical analysis of the development of this profession in the United States and Ethiopia to identify five common themes in the professionalization of healthcare management: (1) a country context in which healthcare management is demanded; (2) a national framework that elevates a professional management role; (3) standards for healthcare management, and a monitoring function to promote adherence to standards; (4) a graduatelevel educational path to ensure a pipeline of well-prepared healthcare managers; and (5) professional associations to sustain and advance the field. These five components can to inform the creation of a long-term national strategy for the development of a professional cadre of heathcare managers in LMIC settings.

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 2159 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.

Background: Quality improvement collaboratives are an increasingly common strategy for implementing evidence-based practices in health care. However, research shows that many participating organizations do not achieve the level of performance improvement desired. Purpose: This study examined the use of interorganizational learning activities (inter-OLAs) as an explanation for mixed performance improvement among collaborative participants. We tested the hypotheses that inter-OLA use is positively associated with participants' performance improvement and that this relationship is moderated by the use of intraorganizational learning activities (intra-OLAs) and quality-focused human resource (Q-HR) practices. Methodology: We conducted a survey of organizational teams participating in 4 Institute for Healthcare Improvement Breakthrough Series collaboratives. Survey responses from 52 teams, regarding the use of inter-OLAs, intra-OLAs and Q-HR practices, were linked to performance improvement data obtained from the Institute for Healthcare Improvement and demographic data obtained from secondary sources. Findings: The more collaborative teams used inter-OLAs, the more their organizations' performance improved. Contrary to our hypothesis, the use of intra-OLAs did not moderate this relationship; teams' use of intra-OLAs added to, but did not multiply, the effect of inter-OLA use. In contrast, an organization's use of Q-HR practices multiplied the performance benefit of inter-OLA use. Practice Implications: Our findings suggest that organizations that participate in collaboratives are more likely to improve their performance if they use the inter-OLAs offered by the collaborative. Our results also suggest that complementing high use of inter-OLAs with intra-OLA use and Q-HR practices enhances performance improvement. For collaborative sponsors, our findings imply that including activities that facilitate interorganizational and intraorganizational learning are worthwhile.

This paper contributes to research on organizational learning by investigating specific learning activities undertaken by improvement project teams in hospital intensive care units and proposing an integrative model to explain implementation success. Organizational learning is important in this context because medical knowledge changes constantly and hospital care units must learn new practices if they are to provide high-quality care. To develop a model of factors affecting improvement project teams driving essential organizational learning in health care, we draw from three streams of related research—best-practice transfer (BPT), team learning (TL), and process change (PC). To test the model’s hypotheses, we collected data from 23 neonatal intensive care units seeking to implement new or improved practices. We first analyzed the frequency of specific learning activities reported by improvement project participants and discovered two distinct factors: learn-what (activities that identify current best practices) and learn-how (activities that operationalize practices in a given setting). Next, ordinary least squares (OLS) regression analyses supported three of our four hypotheses. Specifically, a high level of supporting evidence for a unit’s portfolio of improvement projects was associated with implementation success. Learn-how was positively associated with implementation success, but learn-what was not. Psychological safety was associated with learn-how, which was found to mediate between psychological safety and implementation success.

BackgroundSlow progress in quality improvement (QI) has prompted calls to identify new QI ideas. Leaders guiding these efforts are advised to use evidence-based tactics, or specific approaches to address a goal, to promote clinician and staff engagement in the generation and implementation of QI ideas, but little evidence about effective tactics exists.ObjectiveExamine the association between leader tactics and the creativity, implementation outcome, and evolution of QI ideas from clinicians and staff.DesignProspective panel analysis of 220 ideas generated by 12 leaders and teams (N = 72 members) from federally qualified community health practices in one center over 18 months. Measures were extracted from meeting minutes (note-taking by a member during meetings) and expert panel review. Multi-level models were used.MeasuresLeader tactics, idea creativity, implementation outcome, evolution pathways, center, and idea-submitter characteristics.ResultsLeaders used one of four approaches: no tactic, meeting ground rules, team brainstorming, or reflection on team process. Implemented ideas evolved in three pathways: Plug and Play, Slow Burn, and Iterate and Generate. Compared with no leader tactic, meeting ground rules resulted in ideas not significantly different in creativity, implementation outcome, or evolution pathway. Brainstorming was associated with greater idea creativity, idea implementation, and ideas following a Plug and Play path (low member engagement and implementation over 2 months or less). Reflection on team process was associated with idea implementation (versus not), and ideas following an Iterate and Generate path (high member engagement and implementation over 3 months or more).ConclusionsTwo tactics, brainstorming and reflection, are helpful depending on goals. Brainstorming may aide leaders seeking disruptive change via more creative, rapidly implemented ideas. Reflection on team process may aide leaders seeking high-engagement ideas that may be implemented slowly. Both tactics may help leaders cultivate dynamics that increase implementation of ideas that improve healthcare.

Research suggests that staff voice-discretionary communication of ideas, suggestions, concerns, or opinions about work-related issues with the intent to improve organizational or unit functioning-is associated with quality improvement, which most agree is needed in health care. Nevertheless, health professionals often do not voice. Little research has explored their reluctance to speak up and, relatedly, the conditions under which they voice. We examine the drivers of voice for health professionals in hospitals. Specifically, we investigate the factors that influence their voice, why these factors are influential, and the purposes for which staff use their voice. We conducted a qualitative study using data from 99 in-depth interviews with diverse staff at 12 randomly sampled hospitals in the United States. Data were collected from December 2007 to December 2008, the first year of a 4-year study of improvement. By national standards, all of the hospitals had significant room for improvement in their care of patients experiencing heart attack, suggesting that there were potentially issues and suggestions for staff to voice. Factors related to individuals (e.g., tenure), work (e.g., work configuration), organizational context (e.g., culture), data (e.g., benchmarking), and the external environment (e.g., attention) influenced health professionals' voice. These factors shaped their sense of safety, efficacy, opportunity, and/or legitimacy, all of which affected their belief about the risk and benefit of voice and willingness to voice. They voiced for three purposes: to learn for themselves, inform others, and protect patients. These findings indicate that hospitals and their leaders must attend to multiple factors (e.g., work configuration, culture, etc.) if they wish to increase staff voice in service of quality improvement. The presence of many influential factors suggests that there are several levers that leaders can use to elicit voice, noting that voice can be used in multiple ways to facilitate improvement.