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Service line structure and decision-maker attention in three health systems

Implications for patient-centered care

Louis, Christopher J.; Clark, Jonathan R.; Gray, Barbara; Brannon, Diane; Parker, Victoria

doi: 10.1097/HMR.0000000000000172

Background: Scholars have noted a disconnect between the level at which structure is typically examined (the organization) and the level at which the relevant coordination takes place (service delivery). Accordingly, our understanding of the role structure plays in care coordination is limited.

Purpose: In this article, we explore service line structure, with an aim of advancing our understanding of the role service line structure plays in producing coordinated, patient-centered care. We do so by giving special attention to the cognitive roots of patient-centeredness.

Methodology/Approach: Our exploratory study relied on comparative case studies of the breast cancer service lines in three health systems. Nonprobability discriminative snowball sampling was used to identify the final sample of key informants. We employed a grounded approach to analyzing and interpreting the data.

Results: We found substantial variation across the three service lines in terms of their structure. We also found corresponding variation across the three case sites in terms of where informant attention was primarily focused in the process of coordinating care. Drawing on the attention-based view of the firm, our results draw a clear connection between structural characteristics and the dominant focus of attention (operational tactics, provider roles and relationships, or patient needs and engagement) in health care service lines.

Conclusion: Our exploratory results suggest that service line structures influence attention in two ways: (a) by regulating the type and intensity of the problems facing service line participants and (b) by encouraging (or discouraging) a shared purpose around patient needs.

Practice Implications: Patient-centered attention—a precursor to coordinated, patient-centered care—depends on the internal choices organizations make around service line structure. Moreover, a key task for organizational and service line leaders is to structure service lines to create a context that minimizes distractions and enables care providers to focus their attention on the needs of their patients.

Christopher J. Louis, PhD, MHA, is Clinical Assistant Professor, Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts. E-mail:

Jonathan R. Clark, PhD, MS, is Assistant Professor, College of Business, University of Texas at San Antonio, San Antonio, Texas.

Barbara Gray, PhD, is Professor Emeritus, SMEAL College of Business, Pennsylvania State University, University Park, Pennsylvania.

Diane Brannon, PhD, is Professor, Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania.

Victoria Parker, DBA, EdM, is Associate Professor, Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts.

This research was supported by the Susan G. Komen Foundation (PBTDR12226023). This research has been approved by the Penn State University Institutional Review Board.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

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