I woke up on the cynical side of the bed the morning I went to hear scholarly presentations at a major international conference, the Academy of Management. I chose health care management sessions that I thought would both enlighten and inform me. Instead, I found myself being cynical. The studies were rigorous and the presentations smooth; that was not the issue. My cynicism was sparked, instead, by what I saw as underlying the studies.
Over time, fashionable names for delivery models and approaches have become distracting intellectual trends, despite best intentions for improving quality, cost and access. Various labels have been invented and given to theoretically sound approaches to organization of health care, such as vertically integrated care, integrated care, and primary care medical home. Such labels for diverse organizing approaches emphasize the macro structures of health care organizations. In and of itself, this is not a bad thing, but it has distracted attention away from the fundamentals of doing the work that is giving clinical care. These labels also tend to name the problem (e.g., lack of integration), rather than the desired outcome (e.g., wellness).
Medical and well-care modalities, diagnostics and treatments have become more complex, leading to more players being involved with any single patient. Nonetheless, at the micro level, fundamentally the tasks and activities of delivering care have not changed. What has changed is the vastly increased number of opportunities for the moment of care to go awry. My cynicism comes from an implicit belief among scholars that by changing macro structures all will be fixed, without attention to preserving the micro level service tasks and activities that are “service” and “care”. To be fair, other scholars only focus on the dynamics occurring at the micro level with minimal attention to the influence of structure on the care interaction. Ultimately, delivery of health care is delivery of a service to individuals.
This tension between a micro, interpersonal care perspective and a macro, structural organizing perspective is not new. It forms epistemologies and implicitly drives choices in research topics and managerial approaches. As a key tension within health care organizations and health systems, it deserves explicit scholarly attention and acknowledgement. For example, do we know whether health care organizations structurally change based on findings and recommendations from clinical quality improvement initiatives, and what is involved? Conversely, do we have theories that explain how organizational structural changes ripple into changes in care processes “at the bedside”? Tensions are intellectually interesting and managerially challenging, making them ripe for both theorizing and studying. I acknowledge that the type of multi-level design needed to investigate how this tension plays out in health care organizations can be difficult to fund and carry out. That does not excuse us from, at minimum, contextualizing or embedding the level of the study as a small step toward unraveling the tension.
Health Care Management Review welcomes papers and studies that challenge current perspectives and trends, using grand and mid-range theory development and strong empirical approaches.
L. Michele Issel, PhD, RN