Strategizing to Address Healthcare Disparities

1. Strategizing to Address Healthcare Disparities Case studies of health system partnerships and capacity building activities Professor Lynn Wooten

2. Agenda • Introduction of the Research Project • Framing the Research Issues • The Case Studies • Lessons Learned & Reflections

3. The NIH Roadmap is an integrated vision to deepen our understanding of biology, stimulate interdisciplinary research teams, and reshape clinical research to accelerate medical discovery and improve people's health.

4. Historical Starting Point The rate of infant mortality (widely accepted as an accurate index of general health) among Negroes is double that of whites.” Where Do We Go From Here: Chaos or Community? (Dr. Martin Luther King, 1968)

5. The Public Health Problem • According to "Health, United States, 2000," infant mortality rates are more than twice as high for African-Americans. • Stillbirths • Low Birth Weight (10% of African-American Infants) • Pre-term Delivery (20% of African-American Infants) • Highest infant mortality rate In the developed world

6. In the Popular Press (Essence Magazine, November 2005; New York Times; April 22, 2007) In Turnabout, Infant Deaths Climb in South

7. “Disparities in the health care delivered to race and ethnic minorities are real and are associated with worst outcomes in many cases, which are unacceptable. The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them.”

8. 'U' study seeks to close gaps in prenatal care (Michigan Daily, October 13, 2004) • Closing the gap of disparities has become a major goal for many government agencies, researchers, healthcare organizations and community groups. Although in the past decade prenatal care utilization rates have risen, decreasing the overall infant mortality rate, disparities in infant mortality and other perinatal outcomes between various ethnic and socio-economic groups continue to widen. Moreover, researchers have yet to explain all of the differences in birth outcomes experienced by African-Americans compared to other groups.

9. Interdisciplinary research infrastructure to solve public health problems. Develop testable hypotheses for new effective approaches to public health problems Provide an effective mechanism for communicating research-based information to policy leaders, providers, and patients. Three core areas: patients, providers and leaders The Research Team (17 departments represented at UM) OB/GYN Genetics Nursing Midwifery Public Health Social Work Engineering School of Information Business Sociology Anthropology Medical History The Grant’s Goals

10. Thinking Outside the Box: The University of Michigan Roadmap Team’s Interdisciplinary Model

12. The Organizational Perspective – Research Questions • How can health care systems change from inertia to action in reducing disparities in patient care? • How do health systems frame the problem and its solutions? • Why do health system address this problem? • Who is involved in addressing this problem? Why? • What are the capacity building and organizational competencies associated with moving from inertia to action in reducing disparities in patient care?

13. Research Methodology • Case Study data collected from a “diverse” set of healthcare organizations • Direct Observations • On-site visits • Interviews • Archival Data • Transcribed and Coded into NVivo • Analyzed using a template, grounded theory approach

14. Guiding Theories • Organizational Routines • Skills and capabilities of organizations and its members; the current best practice in an industry; enable organizations to cope with complex problems (Nelson & Winter, 1982) • An executed capability for repeated performance that has been learned in response to selective pressures (Cohen, 1996). • Positive Organizing (Wooten, 2004; Dutton & Glynn, 2007) • Enable organizational resourcefulness • Enhance organizational strengths and capabilities • Expand organizational action repertoires • Collective behavior and relational mechanisms • Capacity Building • The building of an infrastructure to efficiently address health problems (Joffres, et al., 2004) • The development of core skills, management practices, strategies, and systems to enhance an organization’s effectiveness, sustainability and ability to fulfill its mission (Connolly, 2001)

15. Capacity Building in Action:Case Studies of Best Practices Model created by Connolly & Luka’s for the Fieldstone Alliance

16. Case Study Sites

17. Write Individual Case Report Draw Cross-Case Conclusions Conduct 1st Case Study • interviews • observations • documents • pattern-match • policy implications Modify Theory Select Cases Write Individual Case Report Conduct 2nd Case Study Develop Theory • interviews • observations • documents Develop Policy Implications • pattern-match • policy implications • replication Design Data Collection Protocol Write Cross-Case Report • define “process” operationally • define “process” out-comes” (not just ultimate effects) • use formal data collection techniques Conduct Remaining Case Studies Write Individual Case Report • etc. • etc. The Design of Case Study Research (Yin,1989)

18. Template Analysis – Thematically analyzing qualitative data √ Defined a priori theme of capacity building and related codes. √ Transcribed qualitative data √ Initial coding √ Produced iterative version of templates √ Applied template to case sites √ Created case studies based on capacity building templates √ Through out the process quality checks and reflections

19. Framing organizational action through a mission, vision or strategy bring focus, direction and a guiding paradigm. Frames filter, help with sense-making, and provide a roadmap for taking action (Deal & Bolman, 2003; Ancona et al., 1999: Weick, 1995). Framing sends out a message to stakeholders Within the case study, organizations frame addressing healthcare disparities as: As an integral part of their mission An action-based public health initiative A business case An access to care issue Framing: Mission, Vision & Strategy

20. Examples of Framing: Mission, Vision & Strategy • Mission Driven • “Through our exceptional health care services, we reveal the healing presence of God” (Catholic Health System) • “Our mandate is to furnish medical aid and hospital care to indigent and needy persons residing in the hospital district”(Southwest Hospital) • The Business/Market Differentiation Case • Market Positioning -- “We are not a sick plan, but a health plan” (National HMO) • Action based • “Not just another study… but important work being done on the local level to help solve the problem” (City Government)

21. Example: Framing as A Public Health Problem

22. Governance, Leadership & Strategic Relationships Through “Partnerships” • At case studies, City Government and County Health Department leadership and governance emerged through a community health partnership(Weech-Maldonado, Benson & Gamin, 2003); Alexander et al, 2001) • Designed to build on strength of local knowledge about health problems and experiences in service delivery • Support collaboration between the health care system and the community • Partnerships encourage system thinking by taking a population view of health that incorporates disease-based and wellness-based models (Shortell, 1996) • Collateral leadership as a super-organizational phenomenon Enables partnerships to tap into diverse skills and resources through a division of roles (Denis, Lamothe, & Langley, 2001)

23. Community Health Partnerships Partners Partners Initiating Organization Partners Partners Partners Partners • “More than one person or organization is necessary to improve public health … at a minimum academics, health practitioners, and ‘grassroots’ folks.” (County Health Department) • “Local communities cannot solve this problem alone.This needs to be a priority at every level of government, and embraced by organizations throughout the public health and health care system.” (City Government)

24. Partnering as Knowledge & Resource Brokering Initiating Organization Knowledge Resources Knowledge Resources Partners & Clients Partners or Funders • Knowledge brokering focuses on identifying and bringing together people interested in an issue, people who can help each other develop evidence based solutions (Hargadon, 2002; Canadian Health Service Research Foundation). • Examples in the cases • National HMO convened a conference on topic inviting competitors; adopted approach from national think tank • Catholic Health System & County Health Department brokered best practices and knowledge from other industries.

25. Institutionalization & Organizational Learning of Best Internal Operations Management/Program Delivery • Organizational learning is a natural consequence of capacity building through collective leadership. Individual leaders not only bring knowledge into the group, but also create knowledge through a learning cycle(Sandmann & Vandenberg, 1995). • Internal operations and programs emerge from leaders searching for innovative ways to solve a problem, such as by recombining resources, challenging the status quo, or adopting new models (Argyis, 1977). • This requires the involvement of leaders who possess a skill set to identify relevant information, assimilate it, and apply it toward a new programs or processes (Boal & Hooijberg, 2001).

26. Internal Operations Management/Program Delivery

27. Internal Operations Management/Program Delivery (Continued)

28. Impact….Defined in different ways

29. Modeling Partnerships & Capacity Building Activities: From Inertia to Action Capacity Building Organization A Access to Healthcare Quality of Healthcare Individual & Community Wellbeing Organization B Organizational Learning Collective Leadership Through Diverse Partnerships Empowerment & Engagement Organization C Reduction in Healthcare Disparities

30. Lessons Learned: Health Systems Addressing Health Disparities • Committed, collective and visionary leadership. • Framing drives action. • The importance of collecting and analyzing data. • Organizational Learning • Systematic, targeted, and structured programs based on best practices and evaluation.

31. Closing Thought “If you always do what you’ve always done, you’ll always get what you’ve always got. If you want something you’ve never had, you’ve got to do something you’ve never done.” (A.J. McKnight)