Predicting the performance of a strategic alliance: an analysis of the Community Clinical Oncology Program.

OBJECTIVE. This study is designed to examine the effects of environment and structure of the Community Clinical Oncology Program (CCOP) on performance as measured by patient accrual to National Cancer Institute (NCI)-approved treatment protocols. DATA SOURCES/STUDY SETTING. Data and analysis are part of a larger evaluation of the NCI Community Clinical Oncology Program during its second funding cycle, June 1987-May 1990. Data, taken from primary and secondary sources, included a survey of selected informants in CCOPs and research bases, CCOP grant applications, CCOP annual progress reports, and site visits to a subsample of CCOPs (N = 20) and research bases (N = 5). Accrual data were obtained from NCI records. STUDY DESIGN. Analysis involved three complementary sets of factors: the local health care resources environment available to the CCOP, the larger policy environment as reflected by the relationship of the CCOP to selected research bases and the NCI, and the operational structure of the CCOP itself. A hierarchical model examined the separate and cumulative effects of local and policy environment and structure on performance. PRINCIPAL FINDINGS. Other things equal, the primary predictors of treatment accrual were: (1) the larger policy environment, as measured by the attendance of nurses at research base meetings; and (2) operational structure, as measured by the number and character of components within participating CCOPs and the number of hours per week worked by data managers. These factors explained 73 percent of the total variance in accrual performance. CONCLUSIONS. Findings suggest criteria for selecting the types of organizations to participate in the alliance, as well as for establishing guidelines for managing such alliances. A future challenge is to determine the extent to which factors predicting accrual to cancer treatment clinical trials are equally important as predictors of accrual to cancer prevention and control trials.     

Performance in quasi-firms: an example from the Community Clinical Oncology Program

In this analysis, the authors examined the effects of different sets of process, structure, and environmental variables on the performance of the CCOP as a quasi-firm. Specifically, they distinguished between internal organizational processes, structural, and size characteristics of the CCOP and the organizational environment created by prior NCI program experience and the relationship within the quasi-firm. The analysis revealed that these sets of organizational and environmental characteristics have differential effects on treatment accrual. The strongest predictors are those associated with the quasi-firm relationship between the CCOP and its chosen research bases. Any definitive policy implications for the design of organizational network relationships--especially the CCOPs--will require further analysis. Particular attention needs to be given to the longitudinal nature of the relationships and the ability of these organizational and environmental factors to affect other aspects of performance. Several points have been made within this initial assessment. First, the structural character of the CCOP and its relationship to its organizational environment are important factors affecting accrual performance. The subtleties of this multivariate model are not as important as simply demonstrating that the various internal and external characteristics of these organizations as quasi-firms simultaneously affect their ability to accrue patients to clinical trials. Secondly, the importance of research base relations, and particularly the significant role of nurses, needs to be emphasized. While CCOPs were originally designed as a network of physicians and hospitals, it appears that an infrastructure of professionally active nurses working within a larger organizational environment is critical to success--at least as defined by accrual to treatment protocols. Finally, the failure of prior experience with other NCI community programs to affect CCOP accrual performance suggests that such experience does not assure "organizational learning" that may enhance performance. This suggests that CCOPs can be designated de novo to maximize performance without necessarily having to undergo a developmental or experiential phase involving community cancer programs to be effective. However, the authors suspect that another method of characterizing experience may produce different results. Further analyses of these data will test these results against other measures of CCOP performance. Specifically, attention will be given to whether this same set of characteristics is predictive of accrual to cancer control research protocols. Similarly, these same organizational characteristics may or may not be associated with other dimensions of CCOP performance such as changes in physician practice patterns and/or levels of institutionalization of the CCOP within its local community.(ABSTRACT TRUNCATED AT 400 WORDS)     

Interorganizational exchanges as performance markers in a community cancer network.

OBJECTIVE. This study examines how "strategic partnerships" between community-based consortia of oncologists and hospitals (CCOPs) and clinical cooperative groups emerge, develop, and influence patient accruals (i.e., the number of patients enrolled in clinical trials) over time. DATA SOURCES AND STUDY SETTING. Study analyses are based on 65 pairwise relationships that 38 CCOPs established with eight clinical cooperative groups in September 1983 and maintained through February 1989. Data are drawn from grantee applications and progress reports. STUDY DESIGN. The study examines how different types of CCOP-cooperative group exchange relate to one another and to CCOP patient accruals over six time points. Key independent variables include resource dependence, information exchange (i.e., meeting attendance and committee membership), and protocol exchange (i.e., the number of different protocols used). DATA COLLECTION METHODS. Data extracted from secondary sources were entered in a data base. PRINCIPAL FINDINGS. The number of CCOP physicians and support staff who attend cooperative group meetings during the first two years of a clinical research partnership has a significant influence on meeting attendance and protocol use in later years. Two-thirds or more of the variance in patient accruals at each time point can be explained by the number of different protocols used and the number of CCOP representatives serving on cooperative group committees (or attending cooperative group meetings). CONCLUSIONS. The findings highlight the importance of historical relationships and anticipated resource dependence in shaping initial exchange patterns. They also suggest that strategic partnerships need to emphasize structures and processes that encourage early involvement in collaborative activities and that reward participants for maintaining high levels of interaction.     

Expanding the frame of health services research in the drug abuse field.

OBJECTIVE. This article examines the distribution of heavy drug users across health and social service agencies in a community, and ways in which organizational and social policy factors influence pathways to services. DATA SOURCES/STUDY SETTING. Data are from the Community Epidemiology Laboratory, a project that includes comparable surveys of a wide variety of client, service provider, and general population groups in a single northern California county. STUDY DESIGN. The design is a cross-sectional analysis of patterns of service use and referral by heavy drug users distributed across a variety of service settings and in the general population. DATA COLLECTION. In-person, structured interviews by trained interviewers were conducted using comparable instruments, measures, sampling strategies, and fieldwork procedures. PRINCIPAL FINDINGS. The specialty drug treatment system serves only a small proportion of heavy drug users in the community. Large proportions of drug users are found in criminal justice, primary health, and welfare agencies. Patterns of service encounter and referral suggest that drug treatment clients typically have been in jail or on welfare prior to attending treatment, and are far less likely to have been referred to or from treatment by health providers. CONCLUSIONS. Health services research on drug abuse should expand its frame of reference to include services outside the specialty treatment sector. Drug treatment facilities are somewhat remote from other agencies in community service networks and are organizationally dependent on criminal justice and welfare systems. Further research should investigate both the costs and benefits of screening and providing services at earlier points of institutional involvement with drug abusers and the implications of interorganizational dependencies among criminal justice, welfare, and drug agencies for providers and clients.     

Cancer treatment in rural areas

The inability to deliver cancer prevention and treatment to the rural population poses a significant barrier in the national effort to reduce cancer mortality. Since 25 percent of the U.S. population lives in rural areas and few rural areas are readily accessible to cancer centers or Community Clinical Oncology Programs (CCOPs), the prospects for accomplishing the National Cancer Institute (NCI) Goals for the Year 2000 are limited unless substantive changes occur in rural cancer care delivery. This article reviews the problem of cancer risk and care in rural areas and describes one effort to deliver state-of-the-art cancer treatment to rural patients in Virginia. It describes the needs and barriers to access in rural Virginia, the structural elements of the Rural Cancer Outreach Program, and the health policy issues that result when subspecialty care is exported to disadvantaged areas.     

A process evaluation of the National Cancer Institute's Data-based Intervention Research program: a study of organizational capacity building

This paper reports on a qualitative process evaluation of the Data-based Intervention Research (DBIR) program, that was funded by the National Cancer Institute (NCI) and operated in 21 states and the District of Columbia. The goal of DBIR was to build a foundation within state health agencies to ensure the translation of cancer control science into practice. NCI's objective reflected the readiness of cancer control research for public health application, the paucity of cancer control activity within public health settings and the recognition that state health agencies could play a critical role in the effective transfer of research results into public health practice. The qualitative process evaluation reported in this paper is based on one case study of four DBIR programs. The present study indicates that the four state health agencies executed the DBIR program with fidelity. Also, the four states offered a balanced assessment of NCI's role in enabling the state agency operation of DBIR, providing numerous citations illustrating how NCI successfully facilitated organizational capacity as compared to fewer mentions of ways NCI was less than successful. Thus, in funding the DBIR model, NCI was successful in raising state health agency capacity to implement cancer prevention and control programming. Implications for capacity building in state health departments are discussed.     

Three faces of integrative coordination: a model of interorganizational relations in community-based health and human services.

OBJECTIVE. This study develops a theoretically justified, network-based model of integrative coordination in community-based health and human services, and it uses this model to measure and compare coordination in six elder service systems. DATA SOURCES AND STUDY SETTING. We collected data between 1989 and 1991 in six Alabama counties, including two major MSAs, two small MSAs, and two rural areas. STUDY DESIGN AND DATA COLLECTION/EXTRACTION METHODS. Our measurement of coordination is based on patterns of interorganizational relationships connecting the agencies constituting a community-based health and human services system. Within each site, we interviewed representatives from these agencies, asking them to indicate client referral, generalized support, and agenda-setting relationships they had developed with each of the other agencies in the system. Using network analysis procedures we then identified the network associated with each of these organizational functions (i.e., service delivery, administration, and planning) in each site, and we assessed levels of coordination in each network. PRINCIPAL FINDINGS. Our measure of integrative coordination is consistent with other indicators of coordination we derive from our data, suggesting its validity. In addition, levels of integrative coordination across sites for each organizational function are generally comparable. Comparisons across sites show integrative coordination to be consistently highest for service delivery networks and lowest for planning networks. CONCLUSIONS. Previous attempts to assess interorganizational coordination without regard to organizational function are subject to misinterpretation. The differing interorganizational dynamics involved in service delivery, administration, and planning appear to generate different patterns of interorganizational relationships, and different levels of coordination.     

Determinants of children's participation in California's Medicaid and SCHIP programs

OBJECTIVE: To develop a comprehensive predictive model of eligible children's enrollment in California's Medicaid (Medi-Cal [MC]) and State Children's Health Insurance Program (SCHIP; Healthy Families [HF]) programs. DATA SOURCES/STUDY SETTING: 2001 California Health Interview Survey data, data on outstationed eligibility workers (OEWs), and administrative data from state agencies and local health insurance expansion programs for fiscal year 2000-2001. STUDY DESIGN: The study examined the effects of multiple family-level factors and contextual county-level factors on children's enrollment in Medicaid and SCHIP. DATA COLLECTION/EXTRACTION METHODS: Simple logistical regression analyses were conducted with sampling weights. Hierarchical logistic regressions were run to control for clustering. PRINCIPAL FINDINGS: Participation in MC and HF programs is determined by a combination of family-level predisposing, perceived need, and enabling/disabling factors, and county-level enabling/disabling factors. The strongest predictors of MC enrollment were family-level immigration status, ethnicity, and income, and the presence of a county-level "expansion program"; and the county-level ratio of OEWs to eligible children. Important HF enrollment predictors included family-level ethnicity, age, number of hours a parent worked, and urban residence; and county-level population size and outreach and media expenditure. CONCLUSIONS: MC and HF outreach/enrollment efforts should target poorer and immigrant families (especially Latinos), older children, and children living in larger and urban counties. To reach uninsured eligible children, it is important to further simplify the application process and fund selected outreach efforts. Local health insurance expansion programs increase children's enrollment in MC.     

Medical community involvement in a breast cancer screening promotional project.

The analysis, mobilization, and involvement of medical communities in two counties targeted for intervention by the Washington State Community Breast Cancer Screening Project is described. Principles of community organization were applied to the health care sectors in the counties, and the PRECEDE-PROCEED model was used as a conceptual framework for considering individual physician behavior. Quantitative and qualitative medical community assessment methods included a demographic study, a survey of primary care physicians, personal interviews with physicians, and medical office staff focus groups. In both intervention areas, physician planning groups selected, developed, and helped implement intervention activities targeting the health care sectors. These activities included informational mailings to physicians, training of medical office staff members and clinical mammographers, and support for a reminder system. The experience demonstrated that physicians practicing in medium-sized cities are willing to be active in community disease prevention programs.     

Program structure and counselor-client contact in outpatient substance abuse treatment

OBJECTIVES: To examine organizational structural attributes associated with counselor-client contact. DATA SOURCES: Data were collected in 2004 and 2005 for a federally funded project, which simultaneously examines organizational structure, functioning, and resources among outpatient substance abuse treatment programs. STUDY DESIGN: The study uses a naturalistic design to investigate organizational structure measures-ownership, accreditation, and supplemental services-as predictors of time in counseling and case management, and caseload size, controlling for geographic differences. DATA COLLECTION: Directors at 116 outpatient drug-free treatment programs located in four regions across the U.S. (Great Lakes, Gulf Coast, Northwest, and Southeast) voluntarily completed a survey about program structure. PRIMARY FINDINGS: Clients received more counseling hours in programs that were "intensive," publicly owned, accredited, and had a lower proportion of recently hired counselors. More case management hours were offered in "intensive," private-for-profit or publicly owned (versus private-nonprofit) programs, serving a lower proportion of dual-diagnosis clients, and providing more on-site supplemental services. Smaller caseloads were found in programs that were accredited and had a smaller average client census and a lower proportion of criminal justice referred clients. CONCLUSIONS: Organizational attributes are related to counselor-client contact and may have implications for staff turnover and service quality.     

Four degrees of latitude: mosquito control on the "right" coasts of Australia and Florida, USA

This study compares mosquito control within similar environments between 26 and 30 degrees of latitude on the east central coasts of Florida and of Australia. It describes and compares the relevant mosquito-producing environments, the development of mosquito control, legislative framework, funding arrangements, and organizational differences between the areas, including the international interactions that have facilitated good practices. The article identifies some strengths and weaknesses of the programs in each area. Significant strengths include some aspects of funding and administration; collaborations with other organizations; the roles of national and state organizations, including research agencies; and commitment of individuals. Potential weaknesses in programs that are part of larger organizations include their relatively low position in the organizational hierarchy and the need to compete for resources. Programs that are independent districts may lack opportunity to interact with other land management units. Other weaknesses include the relatively high turnover of staff in state environmental resource agencies and the potential loss of institutional memory when long-term mosquito control staff members leave. The case comparison highlights similarities in product use at the individual program level (Indian River Mosquito Control District and Gold Coast Pest Management Unit) and differences in practices including aerial adulticiding being used in Florida but not in Australia.     

Health services for women in outpatient substance abuse treatment

OBJECTIVE: To evaluate how a sample of outpatient substance abuse treatment units respond to organizational and environmental influences by adopting and implementing treatment services for women. DATA SOURCES: The National Drug Abuse Treatment System Survey from 1995 and 2000, a national survey of outpatient substance abuse treatment units. STUDY DESIGN: Health services for women are the dependent variables. The predictors include organizational and environmental factors that represent resource dependence and institutional pressures for the treatment unit. Logistic regression and Heckman selection models were used to test hypotheses. DATA COLLECTION: Program directors and clinical supervisors at each treatment unit were interviewed by telephone in 1995 and 2000. PRINCIPAL FINDINGS: Units that depended on specific funding for women's programs and that depended on government funds were more likely to adopt, but not necessarily implement, women's services. Methadone units and units that train more staff to work with women were more likely to adopt as well as implement women's services. Private not-for-profit units were more likely to adopt some services, while for-profit units were less so. However, in general, neither for-profit nor not-for-profit units significantly implemented services. There was evidence that the odds of adopting services were greater in 2000 than 1995 for two services, but were otherwise stable. CONCLUSIONS: There is considerable variation in the adoption and implementation of women's services. In addition, not all adopted services were significantly implemented, which could reflect limited organizational resources and/or conflicting expectations. This also suggests that referral mechanisms to these services, and therefore access, may not be adequate. Government funds and specific funds for women's programs are important resources for the provision of these services. Women's services appear more available in methadone units, suggesting that regulation has been influential and that the recent methadone accreditation system should be evaluated. Staff training may be one strategy to encourage implementation of these services. For the most part, the adoption of services for women did not change between 1995 and 2000.     

Case management in public health screening programs: the experience of the national breast and cervical cancer early detection program.

This article describes a large public health screening program's early experience in adding case management as a formal program component. The results demonstrate that state and tribal programs participating in the National Breast and Cervical Cancer Early Detection Program have implemented a variety of organizational models for case management of women with abnormal screening results. Programs have different approaches to staffing and reimbursement of case management services, yet most programs have implemented a "patient navigator" or "medical" model of case management service delivery. Although a number of challenges were identified, a clear and positive finding is that case managers are playing an integral role in the transition between a cancer diagnosis through the program and enrollment in Medicaid for treatment services through the National Breast and Cervical Cancer Prevention and Treatment Act of 2000.     

A multi-project systems approach to developing community trust and building capacity.

Community characteristics are being recognized as important determinants for effective community-based programs. Community capacity to collaboratively identify issues, establish collective goals, and mobilize resources is built on experience with such interactions and trust among collaborators. Conceptual approaches and methods to develop community capacity rarely have been a focus of research programs, at least in part due to categorical funding, which often limits the scope and duration of interventions, thereby limiting capacity development. This approach uses multiple categorical funding sources to create sustained community programs involving multiple systems to increase capacity. Quasi-experimental evidence of increases in community capacity within two Alabama communities is presented.     

A comparison of cancer burden and research spending reveals discrepancies in the distribution of research funding

ABSTRACT: BACKGROUND: Ideally, the distribution of research funding for different types of cancer should be equitable with respect to the societal burden each type of cancer imposes. These burdens can be estimated in a variety of ways; "Years of Life Lost" (YLL) measures the severity of death in regard to the age it occurs, "Disability-Adjusted Life-Years" (DALY) estimates the effects of non-lethal disabilities incurred by disease and economic metrics focus on the losses to tax revenue, productivity or direct medical expenses. We compared research funding from the National Cancer Institute (NCI) to a variety of burden metrics for the most common types of cancer to identify mismatches between spending and societal burden. METHODS: Research funding levels were obtained from the NCI website and information for societal health and economic burdens were collected from government databases and published reports. We calculated the funding levels per unit burden for a wide range of different cancers and burden metrics and compared these values to identify discrepancies. RESULTS: Our analysis reveals a considerable mismatch between funding levels and burden. Some cancers are funded at levels far higher than their relative burden suggests (breast cancer, prostate cancer, and leukemia) while other cancers appear underfunded (bladder, esophageal, liver, oral, pancreatic, stomach, and uterine cancers). CONCLUSIONS: These discrepancies indicate that an improved method of health care research funding allocation should be investigated to better match funding levels to societal burden.     

Meeting production: the economics of contracting mental illness

This article presents a case study which illustrates the impact that economic forces can have on organizational structure and clinical practice. Specifically, the stresses and double-binds which staff experience as a result of having to manipulate different sources of funding in order to 'meet production' are examined. Ethnographic fieldwork conducted at a day treatment center connected with a Community Mental Health Center revealed that contracts are made and quotas are set each year to 'produce' different kinds of services. The two main types of services, habilitative and socialization, are not funded equally. Funding agencies pay the most for habilitative services because these are meant to be directed toward the most symptomatic clients requiring the highest level of care. However, who is billed habilitative at any one time may or may not have anything to do with who is actually symptomatic and receiving a higher level of care. The reasons for this are explored, with special attention paid to how staff must adjust to constantly changing funding requirements. Despite the obstacles, staff attempt to provide clients with the level of care that they need, regardless of whether or not this is reflected in production quotas. Taken together, these two elements--the efforts of staff to conform to funding agency requirements plus their attempts to provide clients with the level of care that they need--require that staff engage in a constant and very wearisome juggling act. It is concluded that as a consequence of the demands of meeting production, both staff morale and the treatment of clients is adversely affected.     

What Factors Influence States’ Capacity to Report Children’s Health Care Quality Measures? A Multiple-Case Study

Objectives The objective of this study was to describe factors that influence the ability of state Medicaid agencies to report the Centers for Medicare & Medicaid Services’ (CMS) core set of children’s health care quality measures (Child Core Set). Methods We conducted a multiple-case study of four high-performing states participating in the Children’s Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Grant Program: Illinois, Maine, Pennsylvania, and Oregon. Cases were purposively selected for their diverse measurement approaches and used data from 2010 to 2015, including 154 interviews, semiannual grant progress reports, and annual public reports on Child Core Set measures. We followed Yin’s multiple-case study methodology to describe how and why each state increased the number of measures reported to CMS. Results All four states increased the number of Child Core Set measures reported to CMS during the grant period. Each took a different approach to reporting, depending on the available technical, organizational, and behavioral inputs in the state. Reporting capacity was influenced by a state’s Medicaid data availability, ability to link to other state data systems, past experience with quality measurement, staff time and technical expertise, and demand for the measures. These factors were enhanced by CHIPRA Quality Demonstration grant funding and other federal capacity building activities, as hypothesized in our conceptual framework. These and other states have made progress reporting the Child Core Set since 2010. Conclusion With financial support and investment in state data systems and organizational factors, states can overcome challenges to reporting most of the Child Core Set measures.     

Assessing the impact of continuous quality improvement/total quality management: concept versus implementation.

OBJECTIVE: This study examines the relationships among organizational culture, quality improvement processes and selected outcomes for a sample of up to 61 U. S. hospitals. DATA SOURCES AND STUDY SETTING: Primary data were collected from 61 U. S. hospitals (located primarily in the midwest and the west) on measures related to continuous quality improvement/total quality management (CQI/TQM), organizational culture, implementation approaches, and degree of quality improvement implementation based on the Baldrige Award criteria. These data were combined with independently collected data on perceived impact and objective measures of clinical efficiency (i.e., charges and length of stay) for six clinical conditions. STUDY DESIGN: The study involved cross-sectional examination of the named relationships. DATA COLLECTION/EXTRACTION METHODS: Reliable and valid scales for the organizational culture and quality improvement implementation measures were developed based on responses from over 7,000 individuals across the 61 hospitals with an overall completion rate of 72 percent. Independent data on perceived impact were collected from a national survey and independent data on clinical efficiency from a companion study of managed care. PRINCIPAL FINDINGS: A participative, flexible, risk-taking organizational culture was significantly related to quality improvement implementation. Quality improvement implementation, in turn, was positively associated with greater perceived patient outcomes and human resource development. Larger-size hospitals experienced lower clinical efficiency with regard to higher charges and higher length of stay, due in part to having more bureaucratic and hierarchical cultures that serve as a barrier to quality improvement implementation. CONCLUSIONS: What really matters is whether or not a hospital has a culture that supports quality improvement work and an approach that encourages flexible implementation. Larger-size hospitals face more difficult challenges in this regard.     

Hospital board effectiveness: relationships between governing board composition and hospital financial viability.

OBJECTIVE. Two theories--agency and managerialism--are compared with respect to their usefulness in explaining the role of insiders on the hospital board: whether their participation enhances or impairs board financial decision making. DATA SOURCES/STUDY SETTING. The study used 1985 hospital financial and governing board data for a representative sample of acute care California hospitals. STUDY DESIGN. Relationships were examined cross-sectionally between the presence or absence of insiders on the board and measures of hospital financial viability while controlling for the organizational factors of system affiliation, ownership, size, region, and corporate restructuring. PRINCIPAL FINDINGS. Multiple regression analysis found significant relationships between insider (CEO, medical staff) participation and hospital viability. CONCLUSIONS. These results support the managerial theory of governance by suggesting that the CEO and medical staff provide informational advantages to the hospital governing board. However, the cross-sectional design points to the need for future longitudinal studies in order to sequence these relationships between insider participation and improved hospital viability.