On May 22–24, 2019, at the Organizational Theory in Health Care Conference, held at The Wharton School at the University of Pennsylvania, over six dozen health care management scholars from around the world gathered to discuss managerial and organizational issues that affect health care delivery and, ultimately, population health. The opening plenary for the conference “Moving Organizational Theory in Health Care Forward” was a moderated discussion with five distinguished scholars who have exemplified pushing the frontier of organizational theory and practice throughout their careers: Ann Barry Flood of Dartmouth College, John Kimberly of the University of Pennsylvania, Anthony (Tony) Kovner of New York University, Stephen (Steve) Shortell of University of California at Berkeley, and Jacqueline (Jackie) Zinn of Temple University. The discussion was moderated by Ingrid Nembhard, who co-hosted the conference with Lawton Robert Burns.
The goal of the plenary was to provide an opportunity to hear from senior members of the health care management community how they think about organizational behavior and theory, changes that they have observed, research gaps that they see, and lessons for research and practice that they have learned. In addition, the plenary was intended to ignite discussion among the attendees regarding obstacles to and opportunities for moving the field forward. Originally, the session was to include a sixth panelist, Douglas Wholey of the University of Minnesota, who died shortly before the conference. Wholey, Burns, and Shortell co-founded the Organizational Theory in Health Care Conference 21 years earlier to provide a supportive and productive setting for health care management researchers to develop their work. In recognition of Wholey’s role, the plenary began with reflection about Wholey by Burns and Shortell (Box 1). The following is the transcript of the plenary discussion shared here to capture the intellectual history of the field and help surface the critical advancements still needed in organizational theory and practice in health care.
Reflection: What Motivated My Career in Organization Theory in Health Care
Ingrid Nembhard: To launch our conversation, I would like our panelists to answer these two questions: “What motivated your career in organizational theory and health care?” and “How did you get interested in research at the intersection of organizational theory and health care?”
John Kimberly: Everybody has career trajectories that in some ways are unique, and I would like to address four points that have been key in my own trajectory.
First point: For me, a deep and abiding interest in innovation and change has been the most important motivator of my own career. Those two subjects get me up in the morning and keep me going all day. Looking at what I have published on innovation and change, about half of it is in health care, and that work has been a very important part of my own intellectual journey. I have also taken deep dives in the businesses of higher education and addiction treatment and have worked extensively in the automotive and cement industries as a consultant. Working across industries and seeing innovation and change first hand and up close has allowed me to identify parallels and develop transversal perspectives that have influenced my research on the business of health care. This transversal learning across fields has been important for my own development as a scholar and as a consultant.
Second point: There is, for me personally, a close connection between organization theory on one hand and work and theory in strategy on the other. My own work was initially focused exclusively on organizational behavior and theory but over time has broadened to include strategy, primarily because of my interest in impact and the ways in which organization theory can be of use in the “real” world. In fact, it is difficult for me now to think about organizational theory in isolation from how it is used in the real world. As I think about my personal trajectory, my work has increasingly become influenced by the intersection between organizational theory and strategy.
Third point: An important part of my own learning comes from being exposed to how health care is organized and financed in other parts of the world and particularly in Europe. I spend a lot of time in research and teaching on the other side of the Atlantic Ocean, and it is instructive to see how the problems and issues of health care appear in other contexts. That exposure helps build an appreciation not only for how others can learn from what goes on in this country but also the reverse. There is a lot that happens elsewhere from which we can learn in this country. Living and seeing the back-and-forth has been a very important part of my own story.
Fourth point: An important question that we need to ponder is who benefits from the work that we do. As my career has evolved, the answer to that question has changed. I started out, like many, believing that it is other scholars who benefit most and that it was my intellectual peers who I was most concerned with reaching. But I came to realize that there is a much larger stage, that there are multiple audiences, and that there are many channels for dissemination of our work. Perhaps the most obvious way is through “A”-level pubs, but there are lots of other ways as well. Not everyone can give compelling Ted Talks or radio interviews, and not everyone feels confident writing Op Ed pieces or giving expert testimony. But it is both refreshing and challenging to move beyond the channel of communication exclusively with our academic peers and to recognize that our work can and should have broader impact.
Ann Flood: Ingrid asked: What is your story in getting to here? So let me go back to where I was in the 1970s, when I was first starting out. My background is in mathematics and computer systems programming. I found those sort of boring as I got closer to what I was doing, and sociology seemed to have most of the fun questions but not really necessarily the answers. So I moved into sociology, and then met Richard (Dick) Scott, the primary person that moved me into organizations. The first research that I did was with Dick Scott and Sandford Dornbusch looking at slack. We were looking at professions and organizations that are a little bit weird and the difference it makes when there are mismatches between how people are evaluated and people’s personal goals. One of the things that we looked at was satisfaction. People got terribly dissatisfied in organizations. This was interesting to me. It was fun to study the consequences of organizations. Then, a wonderful thing came along, an issue raised by the National Academy of Science that was posed to five universities. That issue became the focus of my dissertation. The issue was that there was a lot of evidence, revealed through the use of computers, that an awful lot of hospitals had too many surgery-related deaths. It looked like organizations were very much involved in creating adverse consequences like people dying and overspending. I thought that sounded like an important issue. That is how I first got interested in health care organizations. The second thing that drew my interest is the same reason that sociology appealed to me: Health care organizations are truly weird. In 1970, surgeons could go to many hospitals. One surgeon who we studied was privileged at 22 hospitals. It was not uncommon to have privileges at two or three; 22 was a lot. It raised the question: How does a hospital appeal, monitor, and deal with a person who is not a member of its organization? One of the things that hospitals started to do, which blew my mind, is provide each surgeon with his or her desired tools. They said, “we will have different tools for your surgeries, so that nobody else uses the same tools. Another group that you worked with won’t know how to use your tools.” That approach is not oriented toward quality and safety, saving lives or saving money, but it was very much comforted them. Another thing that is weird about health care is that patients aren’t really paying for their care so organizations are not really trying to attract them. Patients think they have choices of which hospital to use but they don’t. They didn’t then either. There was the question of how do you look at organizations then. We didn’t even know to ask about systems. Professions was the major thing that we studied. Interestingly, some of the things that were supposedly the worst things for professionals were what saved the most lives. Hospitals that were highly regimented and had policies that everybody knew were the hospitals that had the best quality of care. It was an interesting tumble of organizational theory as it existed and the reality of hospitals. That grabbed me. That’s the answer to the question of how I found organizations and health care. I have been drawn to its weird and fascinating challenges.
Steve Shortell: My story begins with me wanting to be a hospital administrator and going back home to southern California to get a Master of Public Health degree. After my first year in the program, one of my professors said, “Steve, you write really good papers. Do you know you could do research in this evolving field?” I don’t know if he called it health services research, but for 45 years, that’s what I’ve been doing, writing papers. I got bit by the research bug. I am a very curious person and probably, in another life, could have been an investigative reporter. I just love research. It’s better than being a detective because you get to commit your own crimes. You choose the problems. My professor said there’s two places you should go if you’re interested, the University of Chicago or the University of Michigan. I decided to go to Chicago. At Chicago, I was in the interdisciplinary program in behavioral sciences. After 1 year there, I had a big decision to make. Did I want to be a sociologist that dabbles in health care or was I excited by this complex field of health care and want to get training in different things, including economics so I could focus on health care? I decided to stay in the interdisciplinary program, and that’s driven my career. I wanted to have impact. I wanted to mix disciplines to generate knowledge that’s actionable, that policymakers and practitioners, maybe over time, can use to improve the care that people get. That’s been the central thread in my career. Being at Chicago, you’re imprinted with big theory. My dissertation was a test of social exchange theory going back to George Homans and Peter Blau. I collected primary data over 8 months from 127 internists on the North Shore of Chicago. I conducted an empirical test of social exchange theory among physicians in the area. In those days, we didn’t have fancy computers. I used Hollerith punch cards. It was very early network analysis: Who referred to whom? Was it different by status? What were the rewards and costs? The first two empirical papers from this work were published in the Journal of Health and Social Behavior and Medical Care. Over my career, I’ve basically done work in three areas: integrated care models, delivery of quality care, and, in the last 10 or 15 years, physician practices. We’ve had a lot of research on hospitals, even on postacute care, but not so much on physician practices. The work that I and my colleagues did on integrated care models was drawn on developing accountable care organizations (ACOs). This gave me great satisfaction in terms of impact, on the policy side, which I seldom had had. We are all still looking at these ACOs today. How are they performing and so on? In the quality area, one of my favorite projects was the intensive care unit study with Denise Rousseau and others, from which we published an article in Medical Care on whether good management makes a difference. In another one of my favorite articles, published with Northwestern Kellogg School colleagues, in Administrative Science Quarterly (ASQ), on customization versus conformity, we used institutional and network theories to explain hospital adoption of Total Quality Management, finding early adopters pursue it for efficiency and later adopters implement it for legitimacy. Those are some of my favorite pieces.
Tony Kovner: I am very glad that Steve spoke ahead of me because he recapitulated many of the key moments of my career and how it was determined by chance. I have always felt like an imposter in this group because I am not really an organizational theorist anymore. I am really a frustrated case writer, and most of my work, which has led to research, has involved the writing of case studies based on my research as well as others’ and my life experiences. What had motivated my interest in organizational theory in health care was an experience when I was in the master’s program in health care management at Cornell. My father died, and there was no place for me in my family’s hospital business. I had always planned to be a hospital executive like Steve. My family owned for-profit hospitals in New York City. Then, my uncle sold the business, and there was no place for me. There I was, marooned in graduate school where I was studying to run my father’s hospitals. All of those events led to my interest in organizational theory. I had a wonderful organizational theory background and education, both at Cornell in the master’s program and at the University of Pittsburgh, where I studied under Charles Perrow, the famous sociologist. When I did my dissertation, I applied Perrow’s theories about technology standardization and employee discretion. This is a piece of advice that I give to doctoral students: take your first readers’ theoretical model and apply it to a new set of data. That is the quickest way to get a dissertation completed and help you find out where data are and how you get data. I applied Perrow’s theoretical concept from business firms to nursing units and nonprofit hospitals. I will not go into details about that. I will just say that I became a professor in the business school (here at Wharton), and I subsequently chose to follow Robert (Bob) Eilers’ advice to choose a narrow topic and know more about it than anybody else. Bob was the founding director of the Leonard Davis Institute for Health Economics here at Penn. I chose the governance of hospitals because I still wanted to be a hospital CEO. I spent 12 years managing a variety of organizations—a nursing home, a large neighborhood health center, a group practice in the medical school at the University of Pennsylvania. There I worked with Dr. Arnold “Bud” Relman, who went on to become editor of New England Journal of Medicine, and Dr. Samuel Thier, who became president and chief executive officer of Partners HealthCare in Massachusetts. My career also involved implementing Bob’s vision for the Leonard Davis Institute. Together with Bob, William (Bill) Kissick, Daniel McGill, and others, we learned on the job about organizing research, teaching, and service. I also learned a great deal by being the member of two interdisciplinary and intersectoral teams. One was organized by Richard Chait on governance research, and one organized by Denise Rousseau on evidence-based management. It’s the people who I have encountered who have helped make a career at the intersection of research and health care meaningful for me.
Jackie Zinn: Academics was a mid-life career change for me. I was a hospital administrator. I worked in planning at the Hospital of the University of Pennsylvania, had an MBA, and so, in effect, I was doing health services research, but with an operational focus. I felt the need for more structure. Fortuitously, and a lot of my life has been fortuitous, Wharton was just beginning its doctoral program in health services research. I applied, was accepted, and that was the beginning of my academic pursuits. The way the program was structured, you could enter into different disciplinary tracks. I took John Kimberly’s outstanding course in organizational theory, got hooked on it, and that shaped the conceptual framework that dictated the way I thought about organizations. During my time in the program, I was a research assistant to Risa Lavizzo-Mourey, who had a grant to look at how you avoid hospitalization of nursing home patients. I spent a lot of time in nursing homes and was astounded by how little organizational analysis was done there. That observation brought to mind a conversation I had with Jon Chilingerian. We were talking about strategies for promotion and tenure, and Jon said to me, “Jacqueline, you’ve got to find a niche. You’ve got to find an area where very few people do research. When external reviewers are asked the question, is this person the top five in his or her field, it helps if there are only five people as opposed to 500 people.” With that inspiration, I decided to look at how market structure, particularly competition, impacted nursing home quality. I had my research question. The difficult part was how to test it. I searched for a data set, and in my moment of near final desperation, I connected with the Betsy Cornelius who was at the Health Care Financing Administration, which is now the Centers for Medicare & Medicaid Services (CMS). She said, “We’ve got this data set called Oscar. It’s the annual Medicare nursing facility certification data. If you want it, you can have it.” It worked. The takeaway of my dissertation was that competition enhances quality in nursing homes. Competition was a good thing because this was a for-profit environment for the most part. That result got attention because it was unexpected. It also got me a job at Temple. So there you have it. I then looked at whether nursing homes that appropriately structured work to fit their task technologies had better quality of care. Steve, I do not know if you remember this, in Las Vegas, underneath the Keno boards, you met with Diane Brannon and me to talk about a project. That was so significant for me because it was my first collaboration, a collaboration between Vince Mor and his group at Brown University, Diane and her group at Penn State, and Temple University. It was also my introduction to primary data collection and the perils thereof. Primary data collection is getting more and more difficult. Sometimes that is the only way to get the information you need, but organizations are deluged with requests so it will be more and more difficult to come by. That is a challenge for organizational theory growth in health care.
Significant Advancements: Achievements and Opportunities
Ingrid Nembhard: I thank each of you for sharing your journey and what made you integrate organizational theory and health care. Now please reflect on the field as a whole: “What do you think have been the most significant developments in organizational theory and health care? And, what do you see as opportunities for moving forward in this space, both in theory and practice for health care? What will it take?” Some of you started to touch upon these questions already. I am inviting you to elaborate on where we have been and where we can go.
Steve Shortell: Imagine a Venn diagram with three circles. One circle has to do with problems and issues that interest you about health care and health care delivery. The second bucket has to do with the ideas you have and the theories that you’re drawing on or interest you to address those ideas. The third has to do with data. Some of the biggest changes I’ve seen are around the problems and issues studied. In the 1960s and 1970s, it was very much around cost, access to care, and so on. Health services research was dominated by economists. Legitimately so. Organization theory was just beginning to emerge. This conference didn’t exist in those days, but if it did, it would probably have had six or seven people, including the five of us up here. In the 1980s and 1990s, the big concern was quality of care. Now, in 2010 and 2020, it’s the value. Are we getting value for this great investment we’re making? Data is huge for answering these questions. The changes in data have been large. When I did my dissertation, you didn’t have the data. The economists did. They had cost data. You had to collect a lot of primary data. These days, you might gather primary data using some qualitative methods and, of course, through surveys, but it is becoming increasingly difficult.
Additionally, we realize now that what really determines health is not a lot of the things we study. We tend to focus on the medical care system, which is a “fix me up” thing. It is very important to use when we need it. There is no question about that, but the field has shifted and moved toward population health. We now see the permeability, if you will, across sectors, between the formal health care delivery system and social sector agencies, transportation, housing, and so forth, which brings back the importance of the work that’s been done in our discipline over the years, on interorganizational relationships and networks. Amanda Brewster at University of California-Berkeley, and some of you here, are doing great work in that area. I think that it is clearly going to be one of the big areas for research and impact in the future. And, the whole area that, Ingrid [Nembhard], you’ve opened up, along with colleagues, around the need to get people and groups and organizations to learn more quickly because of the acceleration of change that’s going on every single day. Machine learning, neural networks, and all of the other things that generate new data are key too. How is the health care system going to adapt to all of this? Learning at multiple levels is another area for research. Michael Harrison and I have been thinking about that, and some of you have, as well. Those are just a couple of the areas that come to mind for me.
Let me now throw out a thought to see what all of you think. I’m not so sure there have been many advances in theories over the years. Forgive me, Jill [Marsteller], I’m going to read from your journal. Jill is the new editor of Quality Management in Health Care. Here is what she says are the kind of articles that she wants as she moves that journal forward: “We anticipate continuing to publish quality studies in quality improvement, implementation science, organizational learning, change management, organizational structure, coordination, organizational behavior, behavioral economics, and organizational economics, in addition, to health policy, strategic management, team science, social networks, psychology, and sociology, among other fields.” What does it mean that we have an extensive list of topics or theoretical areas like this, which have been around for decades, and yet I am not sure there have been as many advances in theory related to them.
Tony Kovner: A significant influence for me was the work of sociologist Eliot Freidson on the profession of medicine. Another is the contribution of Dr. David Sackett and his colleagues on evidence-based medicine, which led to the concepts of evidence-based management and evidence-based practice. Also very noteworthy is Amy Edmondson and her colleagues for theory and research on mentoring and effective teaming. What lies ahead for the field is increasing understanding of how to make health care delivery more humanistic as a result of artificial intelligence (AI). Eric Topol has written a book, called Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again, on this subject. It is important that AI doesn’t end up like electronic health records, controversial and also proprietary. Of course, I am particularly interested in the future of governance and the mechanisms of accountability, particularly in nonprofit organizations. Further work has to be done in that field. I want to close by saying that, in part, what it will take to advance organizational theory in health is for members of this audience to take greater ownership of your work toward improving health outcomes. I think that has been the greatest defect of this group over history. We need to take greater ownership of our doctoral programs. Career progression should involve learning from related disciplines and sectors. I hope this will be a consequence of this timely and important conference.
John Kimberly: What are some of the areas that I see as opportunities for organizational theory in health care work? There are four. One is the “I” word. Implementation or implementation science. Second is artificial intelligence. Third is big data and analytics. Last, but not least, is the role of organization theory in a digital world. Piggybacking on what Steve and Tony said, one of the areas that I think is wide open for us and where we not only can be useful but where we should be is this area of organization theory and the digital age. Challenges to management in a digital world are very different. We ought to be the leaders in trying to figure out what those differences are and what kind of differences those differences will make. We should study organizations in the digital age and consider what kind of lenses we can use to understand that. I am taking a very deep dive with a French colleague of mine into Uber. Uber is not a health care model but is so interesting because, as an organization, their management has to be on 24 hours, 7 days a week. When you think about the kind of challenges that organization faces, and that some of the challenges might appear in health care too, it seems that that area is wide open for interesting and innovative contributions from us. Another opportunity area is an old issue but still front and center. Tony cued this up for me in his remarks, and that is the role of for-profit enterprise in health care. There are still debates about the appropriateness and the consequences of for-profit enterprise in the health care space in general and in particular sectors of the health care space. We are equipped to bring insight to that debate, and we need to do it. It’s important for us to try to tease out how to balance concerns with making money, and “no margin, no mission.” Likewise, we need to offer insight on how to balance forces of proprietary progress, on the one hand, and high-quality, sensitive, sensible care, on the other hand.
Ann Flood: One of the things I was thinking about from all of this is, first of all, the agreement that maybe we haven’t advanced organizational theory all that much. It sounds very familiar, and not just because we are up here reminiscing. A thing that has happened in my career in the last 10 years is moving into both device development in the medical field and to clinical research. That was not the kind of data collection in which I had been involved. My data were always computer-based, using Medicare data, Medicaid data, and so on. Recently, I have become much more involved in trying to figure out how to get innovative systems out of academic use and clinical studies and back into real care to make a difference. It is shocking to see how hard that is and how few, for a whole variety of reasons, ever make it out. One estimate is that one in a thousand major innovations actually gets used in health care.
Tony Kovner: You could say the same thing about dissertations.
Ann Flood: Probably one in 10,000 there. Some of it is still how do you bring the things that we do in organizational theory to what is actually a very turgid, very difficult area. It is multidisciplinary work, and most researchers do not think about organizations. They do not think about fitting their innovations into the health care setting. They do not make it easy for people in health care to be able to use their machines. It seems to me that, even if we don’t have that many more advances in research or theory (I think there are some happening), there is still value in areas of research focused on using some of our insights to help bring things forward in areas like clinical research and, in particular, in device research. Everybody says, “it’s just like drugs, just apply whatever is true in drugs.” For all kinds of things, they say just call it the same, if it is a device. Having tried now to develop that perspective, I see that they really are quite different. The other area that I have been involved in is trying to figure out how to both manufacture devices to solve problems, not only in a public health setting like Steve was talking about but in the 9/11 kind of settings. I have been involved in trying to look at what happens if you have a million people that need to be evaluated in 6 days because in one confined area they have just been exposed to radiation. You cannot tell them, and there is no way in the world that the local health care system can deal with a million people showing up. They don’t know how to deal with them, let alone what to do with them. It is a fascinating problem that gets more into the public health arena to apply organizational theory. So my advice is to look at new organizational theory, but like Jackie said, go where there are only five people in the field.
What Will It Take to Move Forward: A Group Discussion
Ingrid Nembhard: Let us open up the conversation now to remarks and reactions from everyone here to what has been said and sharing of other thoughts. Maybe questions for all of us to think about are: Where do we see our field growing? What are the developments? What will it take for us to move organizational theory in health care forward?
Robert Burns: Let me just remark that I heard a lot of big picture themes that were important back in the 1970s and 1980s that are still big today. I do not think we have plumbed the depths of all of them. Steve, you mentioned interorganizational relationships with these large networks and reaching out to community-based agencies and all that. In 1975, Edward W. Lehman published a book called Coordinating Health Care: Explorations in Interorganizational Relationships. That was the second book I read about health care, and that stuff is still important today. We just kind of lost track of it. It has become even more important due to all of the alliances and networks occurring today. Tony mentioned governance, which is incredibly important, especially in accountable care organizations and with the multiple participants in these networks. Who is running what? Who has the decision rights? How do you get all these parties to work together? Incredibly important.
John and Jackie, I know that you spent a lot of time studying corporate strategy. I have always viewed corporate strategy as natural bridge for us to work with economists. They view corporate strategy in terms of industrial organization, but it is basically the same stuff that we study. They just have a different nomenclature for it. A lot of corporate strategies have impacts, both good and bad. Ann talked about technology and workers. We used to call that sociotechnical systems. We now call it human factors engineering. That’s where technology meets people. Tony, that is why electronic medical records haven’t worked, because of the pushback from the people who were supposed to use it. And Tony, the work that you did on evidence-based management, and how we expect physicians to practice evidence-based medicine but what about hospital executives practicing evidence-based management? It appears that we could have a real impact by just getting people to stop making dumb decisions.
Steve Shortell: I just want to underscore what Rob has said. There was conference in Seattle around 2004, and the organizers asked a few of us to address the challenges at that point in time. There’s an issue of Medical Care Research and Review that highlights that discussion (volume 61, issue 3 supplement, September 2004). I’ll share three questions that we raised in that issue. The first is: Why do we have such a large amount of unwarranted complexity and variance in the quality and outcomes of care? Second question: Why aren’t evidence-based medicine and evidence-based management implemented more in everyday practice? Sociotechnical systems. The lean management system is the modern-day reflection of that. Third question was: Why are there no health care organizations today that provide uniformly high quality across the board? It’s 15 years later, and we don’t know any more about that. Maybe a little bit more, but we do not see the numbers changing a whole lot. I would assert that those three are still very salient questions for us to address today.
Jackie Zinn: I want to provide just one example that illustrates what Rob said about the expansion of networks to include organizations other than health care. For about 15 years, I was on the board of the Inglis Foundation, which formed in the Victorian era, and called the Home for Incurables because it provided shelter for people with profound physical disabilities. That mission has not changed, but what does Inglis do now? They do housing because people do not want to be warehoused. They do not want to be isolated. They want to be in the community. They need support that will enable them to do that. Think about that the World Health Organization definition of health. It is more than the absence of disease. We have to bring these social organizations into the network if we are going to achieve that.
Steve Shortell: Picking up on what John and others were mentioning about devices, take a look at a recent book edited by Susan Dentzer on distributed care, Health Care Without Walls: A Roadmap for Reinventing U.S. Health Care, which discusses telehealth, wearables, digital devices, and so forth. It is a quick easy read. Questions that we can address leap out of that.
Audience Member Sara Singer of Stanford University: My one thought, for the group to think about, is when we think about health care organizations, what organizations are we talking about. I would encourage people to think beyond organizations that fit within the traditional medical sphere. Think about all the ways in which other kinds of organizations can impact health. For example, construction companies in the way they build houses and all of the employment situations where we are working and spending a lot of our time, and the way that those organizations are contributing to health. There are multiple settings for thinking about how organizational theory and health care interrelate, an untapped opportunity.
Audience Member Michael Harrison of the Agency for Healthcare Research and Quality (AHRQ): Three short comments. First, a footnote to Steve’s remarks about the ease of data access now. The Comparative Health System Performance data set, created by AHRQ, is now publicly available and includes most of the organized health systems in the country. My second comment is on multiple chronic conditions and aging. The nature of presentation to the delivery system is changing radically. The delivery system is set up in professional and functional divisions to treat single elements. A population with multiple chronic conditions and aging is a new form of complexity for the system, which is a huge challenge. My third comment relates to John’s remarks. If getting an available data set is a short route to a career, here is a long but meaningful route: international comparisons. You can learn an incredible amount if you study another system or two. One of the things that I learned from looking at systems in Europe is how incredibly influential professions still are. Despite national variations, there is still an incredible amount of continuity when you look across systems in the impact of professional norms on the way care provided care is defined.
Audience Member Martin Charns of Boston University: I want to raise the issue of research on implementation at multiple levels. If we look at implementation science as an example, it as a field is very micro. If you look at the literature, there is very little recognition of context, although the field is now moving that way. If we do more research that looks at multiple levels, I think we can be much more informative. In real life, interventions are likely to be more effective, whether it is a technology or a change in practice, if you know what might be needed at multiple levels. The reason that I am raising that is to complement the view of looking across organizations. We should also look across levels, vertically.
Audience Member James Barlow of Imperial College, London: There is a lot to learn from complexity science and complexity thinking and, in the United Kingdom, certainly more discussion about what this means for improving the National Health Service. The point about the best scale and level in the system for intervention is extremely important. We often forget how interventions ripple through the system in all sorts of different and sometimes unpredictable ways. I really just need to make a plea: inject a bit of complexity thinking into discussions around organizational theory. I also want to agree with the points about housing and the role of housing in health care. It is such a fundamental part of care. The whole delivery of care is moving toward communities, and we have to embrace that.
Audience Member Valerie Lewis of the University of North Carolina at Chapel Hill: I have a question that I was curious if the panel would address. When you look at what is going on in health care and in our field, what do you think the barriers are to organizational theory, organizational research, and making more of an impact on what is going on? When I think of contemporary policy and everything that is going on to change health care, it seems like economists still have a great position. They have a good voice; it seems like we have less of a voice. Even with AHRQ’s Comparative Health System performance initiative, there are some organizational researchers involved and it is an initiative focused on organizations, but there is still a limited voice of organizational scholars.
Steve Shortell: My perception might be slightly different. Part of it may be that people know what an economist is, who an economist is. Health economics as a field has been around since the 1960s, perhaps earlier, so the professional identity is very clear to people. An organizational theorist or an organizational behaviorist? What are we? Who are we? Psychologists? Sociologists? We do not have as coherent professional identity as economists. There are people working at CMS who are influencing policy, who are not economists, and that are having increasing influence. Maybe not as much as we would hope, but they are not branded as an organizational theorist or organizational behaviorist. We are a much more eclectic group of scholars. In the design of the accountable care organizations, Dr. Elliot Fisher of Dartmouth College (a physician and health services researcher, not an economist) played a key role in drafting the legislation drawing on our work and others. Afterwards, a number of us published articles in the JAMA (Journal of the American Medical Association) on what CMS ought to do, suggesting various risk levels tied to the ability of physician organizations to develop the capabilities to assume risk. I think that we had quite a bit of influence on some of that, and there are other examples. But your point is well taken. It can be more, and there is an opportunity now, working with economists and others around implementation issues and multilevel issues. It is not just financing and coverage. If you get universal coverage, how is it going to be affordable and sustainable over time? That has to do with social determinants, yes, but also with the delivery system and care delivery. These are the kinds of things with which behavioral scientists and organizational theorists have a comparative advantage. Behavioral economists are important too.
Tony Kovner: How is that going to happen, Steve? What is the process?
John Kimberly: Well, it is already happening. Behavioral Science and Policy journal now exists, and its sponsoring association is on the ground. They have been in existence, I guess, for 3 or 4 years. I see that as a very positive development for the integration of behavioral science know-how, knowledge, and understanding into the policy arena and into organizational improvement. I think that it is huge, Tony. When you look at the membership of Behavioral Science and Policy, the people who are on the various boards, and the review panels for articles in Behavioral Science and Policy, I think there is a lot of hope there. There are a lot of positive people.
Ann Flood: One of the elephants in the room that I am sure you know about all too well is that some of what we are saying is a message that is not particularly welcomed by the organizations that we are trying to change. The more that we try to change them in ways that might improve the health of the population and improve the health of the organization but does not improve their bottom line, the more they are not quite so interested. That is an issue. I do not know how we deal with that, but that may be part of the problem.
Steve Shortell: One way you deal with that is from a policy perspective. Move toward global budgets and what CMS is trying to do. Align financial incentives so that organizations are incented to keep people well and out of hospitals and emergency rooms. Reach out to housing and other sectors in order to do that. We are not there yet in this country.
Audience Member Christy Harris Lemak of the University of Alabama at Birmingham: I am struck by the opportunity. This is not really a question as much as it is a statement. The levers for changing the behavior of organizations. There is a policy lever and how we incentivize or otherwise set up policies. There are also the levers of the organizations themselves. I also think we have an opportunity to use our own students. The leaders in our classrooms are often the ones driving behaviors and policy. Whether they are in our executive programs or in our early career programs, the more we use our science to teach and show that evidence can lead to better decisions, the more impact we can have. Sometimes we separate our lives. This is a theory conference, not a teaching conference but, as scholars, we have a responsibility to say, “how do we develop a future generation of leaders?” We don’t just want to say to them, “I hope you read my papers.” Thinking about how you have done that, maybe that is the question. How have you done that in your career successfully? What have you learned about how to do that?
Tony Kovner: The way to do it is to get chief executives involved in the work that you do and get them to take ownership of our ideas as their ideas. That is how you get change.
Steve Shortell: Christy, I don’t know if this is what you had in mind. I’m sure a number of us have our students go into organizations to do strategic plans or whatever change management, then bring that back to class. At Berkeley, we always require them to present to the Chief Executive Officer. I am more optimistic than I used to be because of the changes in payment systems, in particular, but in other domains as well. We are beginning to see some very interesting things happen but there could be a lot more. Something that I do is try to notice two or three students each year who I want to try to stay in touch with after they graduate. You can then be part of their journey as they advance in their careers. For example, I have a former student who is now the number two person at a big health system. He occasionally will call me and say “Steve, what do you think of this?” I may influence that person a little bit. I do not know what other strategies people have, but you’re right, we are training the future change-makers.
Jackie Zinn: How many of you bring your research into the classroom? Particularly those of you who are teaching MBAs. Following up on what Christy was saying, you bring it in. That is kind of simplistic, but it is an easy way.
Steve Shortell: That is a selling point. You say, you come to Berkeley and you will learn about it first. Otherwise, it is going to be out in some journal in 2 years and everyone can get it. We can all say that about our universities. You bring your research into the classroom, you’re going to get it right here. Professor Hector Rodriguez at Berkeley says, “Here is the latest knowledge about how best to promote patient engagement.” By the way, this report just came out from National Academy of Medicine, The Future of Health Services Research—Advancing Health Systems Research and Practice in the United States. You may want to scan this.
Ann Flood: How come it’s so little?
Steve Shortell: They want it read. The other thing you should be aware of is that AcademyHealth, with money from the Robert Wood Johnson Foundation, has initiated a project to redefine the field in which most of us are working. The project is called the Paradigm Project, and it is going on over the next 3 years. It is trying to address some of the points that we are discussing, and questions like how do we develop embedded research models into large delivery systems and how do we build bridges between academia and embedded health systems, for examples? This is something for all of us to track over the next few years. It is an interesting development.
Updating Views on Organizational Theory
Audience Member Michaela Kerrissey of Harvard University: Looking back to the past, I would like to hear about ideas from early in your career that you no longer believe. What enabled you to update your thinking? How did you come to see the world afresh?
John Kimberly: That is an interesting question. I am going to speak about something you did not expect. In the early phase of my career, I thought that my professional goal was to write in a way that would appeal to my colleagues. Get up in the morning and polish, polish, polish. Publishing my first piece in ASQ was huge. When I got the positive response on that piece, I was in heaven. I now believe that it is still important to communicate with colleagues in a rigorous and meaningful way but there is so much more that needs to be done. I really moved away, not away from that, but moved to a much broader sense of what the role of the researcher, and well, organizational theory in health care more broadly, can involve. I would almost go so far as to say, should involve. That is a major shift in my own thinking. Another shift that is related is the relationship that I have with the media. Initially I thought my obligation was to talk with my colleagues, and it is for others to figure out the utility of what I do. That was not my role. That was somebody else’s role. I do not believe that anymore. I think I have an obligation to be out there trying to demonstrate, in a variety of ways, to variety of different media, what difference the kinds of things that I think I know make. I do not believe anymore that it’s sufficient to toss my papers at the outside world and let them figure out what to do with it.
Ann Flood: Continuing on that theme. I have been involved in decision-making in health care, which evolved from focusing on how physicians make decisions to how organizations make decisions to how patients make decisions, especially when there is not a right or wrong answer. One of the things that was most surprising in that shift was how hard it is—how hard it is to try to give somebody a balanced view and to give something because we are oriented toward persuading instead. When people hear information, it is often proceeded as “am I persuaded to do something?” If you change your approach to say, “I want to give you a balanced view so that you can make up your own mind,” it seems almost more impossible. I did not realize that starting out. It should not be that way.
Jackie Zinn: That is a very provocative question. There is no unified theory in health care. There is a multiplicity of theories, and they have been around for a long time. Have any of them been conclusively disproved. Any theory? Has anyone said “toss that one out because it just doesn’t work”?
Steve Shortell: I would simply add maybe two things. I am very much a product of where I am and who my colleagues are. Very much influenced by them. Think about that, who those people are for you. Some of them are here. What can we learn from them? What are their comparative advantages? What are yours? I went back and forth between business schools and schools of public health. At one point, it was like John said, the coin of the realm was you publish in ASQ, etcetera. So I did that and was influenced by my colleagues. Then in the School of Public Health, I always wanted to have an impact on the health care sector. That is why I did not become a “sociologist” sociologist, although I am a card-carrying member of the medical sociology section of the ASA. The point being I became more applied. I do not like that term in my research. I did not care anymore whether a paper was positioned for ASQ or American Journal of Sociology. It was really going to get into a health services research journal. That was influenced by who was around me, who could I learn from, and what I could contribute to what they were doing. The second thing, when I started out very early on right out of a doctoral program, was not understanding the complex adaptive system and how complex the health care sector is that we’re trying to study. Over time, I have shifted greatly to appreciate how complex it is, multilevel, and so on. Recognizing that it is a complex adaptive system, I’ve become much more contingent and nuanced in my approach. Maybe more humble in terms of limitations as well.
Final Thoughts (for Now)
Ingrid Nembhard: Let me ask one closing question: Is there something that you want us all to keep in mind as we think about organizational theory and health care going forward. Is there anything left on your mind or that you just put this out there for this group to consider?
Steve Shortell: I would say there is a great need in our field for staying with issues over time. The longitudinal analysis of issues over time. It is hard to do that. Are we going to get the data sets? Sometimes you have to wait for them. Then you have to collect a lot of the independent variable data that are not in data sets, and a lot of the outcome measures that you would like to use are not in existing data sets. A lot of primary data collection is required. We have a great national data set now on physician organizations. Our team originally had a proposal to update it every few years but was not able to because we did not have the funds to support it. So how do we get to be able to look at changes and stay with issues over time? It is a challenge for us. I think we ought to push for funding from public agencies and explore ways in which it can be easier to access and link data than is currently the case.
Tony Kovner: I think that the big question is when is the timing right for the research that you want to do? I remember that when I talked to Samuel Thier about his career choice, he said that, “I chose nephrology because at that moment, in all the medical specialties, the research was ready to be made, and I didn’t just do what I wanted to do. I did the research when the timing was right to do that research.”
Jackie Zinn: Do not be afraid to take risks. Some way or another we have got to get ahead of the curve if we’re going to influence policy and practice and not be consistently catching up. That involves taking some risks but the returns may be worth it.
Ann Flood: I think women are much more likely in organizations to take risks so it is very appropriate that Jackie said that. Another thing is to have impact. You need to remember the big picture because if it does not really make a difference, then why are you doing it?
John Kimberly: One of the underlying themes that impressed me today is the fascination with large-scale data sets and the easy availability. I understand the utility that large data sets provide for answering new types of questions but I think that we should not lose sight of the fact that there are everyday things that happen on the ground, on the front lines, that are not reflected in large-scale data sets. We need to understand them if we are going to move the needle on improving quality and improving outcomes. I guess the easy answer here is to take the multimethod approach. Who could be against that approach? Well, I suppose maybe somebody could be. I personally believe, very, very strongly, in the importance of this research in which my colleague, Etienne Minvielle from France, is expert. It is on the ground. It is trying to understand the real issues that people who are in the delivery process, including patients, are facing in the trenches. It is so easy to lose sight of the sort of textual quality of all that in large-scale data sets. This is not a critique of large-scale data sets, but it is a plea to remember that what happens inside the organization is hugely important and we need to be on top of that.
Ingrid Nembhard: My thanks to all of you for an engaging discussion. I would like to close with a summary that does justice to the discussion but I know that I cannot. What I will do instead is summarize the concluding comments of our panelists into five suggestions for how we move organizational theory in health care forward: (1) perform multimethod studies that allow us to “be on the ground,” don’t just rely on large data sets; (2) don’t be afraid to take risks; (3) pursue longitudinal studies and external support for this; (4) consider the timing of our work; and (5) strive for impact. Don’t forget that last one. Let’s all strive to have meaningful impact on organizational theory and practice in health care.