Organizational technologies for transforming care: measures and strategies for pursuit of IOM quality aims

Progress on the Institute of Medicine's (IOM's) 6 aims to bridge the "quality chasm" requires both measurement and the concerting of multiple organizational technologies. The basic thesis of this article is that rapid progress on the IOM's multiple aims calls for transformative change within and among healthcare organizations. The promise of a number of types of transformative approaches is closely linked to their ability to simultaneously build upon several organizational technologies: clinical, social, information, and administrative technologies. To encourage and advance such efforts, this article identifies illustrative measures of attainment of the IOM's 6 aims or targeted areas for improvement that reflect the contributions of the 4 organizational technologies. It discusses examples of relationships between the IOM aims and the organizational technologies considered. Finally, the article offers illustrations of the interplay of these organizational technologies and IOM aims-across an array of organizational innovations with transformative potential. Included among such innovations are information technology in the form of electronic medical records, computer-based physician order entry, and patient health records; organization-wide patient-centered cultural change such as Studer's Hardwiring Excellence; Six Sigma and Toyota Production Management/LEAN; major clinical technology change, for example, minimally invasive cardiac surgery and broader treatment innovations such as disease management.     

Education for Self‐Support: Evaluating Outcomes Using Transformative Learning Theory*

This paper describes the use of transformative learning theory to evaluate a family‐empowerment project focusing on life skills. The project was designed in response to welfare reform in Montana. Open‐ended interviews were conducted with 34 participants. Results revealed evidence of transformative learning outcomes such as an empowered sense of self and new connectedness with others. Respondents also spoke of factors built into the program designed to foster transformative learning. Implications are presented.     

Transformative change in <Emphasis Type="Italic">Invasion of the Body Snatchers</Emphasis>

Transformation is a memorable feature of some of the most iconic works of science fiction. These works feature characters who begin as humans and change into radically different kinds of being. This paper examines transformative change in the context of the Invasion of the Body Snatchers movies. I discuss how humans should approach the prospect of being body snatched. I argue that we shouldn’t welcome the transformation even if we are convinced that we will have very positive experiences as pod aliens. When considering a transformative change, it is appropriate to give priority to your pre-transformation attitudes to potential future experiences and achievements over your predicted post-transformation attitudes.     

The redundancy of positivism as a paradigm for nursing research

New nursing researchers are faced with a smorgasbord of competing methodologies. Sometimes, they are encouraged to adopt the research paradigms beloved of their senior colleagues. This is a problem if those paradigms are no longer of contemporary methodological relevance. The aim of this paper was to provide clarity about current research paradigms. It seeks to interrogate the continuing viability of positivism as a guiding paradigm for nursing research. It does this by critically analysing the methodological literature. Five major paradigms are addressed: the positivist; the interpretivist/constructivist; the transformative; the realist; and the postpositivist. Acceptance of interpretivist, transformative or realist approaches necessarily entails wholesale rejection of positivism, while acceptance of postpositivism involves its partial rejection. Postpositivism has superseded positivism as the guiding paradigm of the scientific method. The incorporation in randomized controlled trials of postpositivist assumptions indicates that even on the methodological territory that it once claimed as its own, positivism has been rendered redundant as an appropriate paradigm for contemporary nursing research.     

On the body of the consumer: performance‐seeking with wearables and health and fitness apps

Contributing to critical digital health research and the sociology of health consumption, this study investigates the phenomenon of self‐tracking and interpretation of consumer data via wearable technology and mobile fitness software applications (apps). It critically analyses qualitative data collected from members of running communities in the UK who are heavy users of apps and wearables. The study seeks to understand the meaning and practise of long‐term use of apps and wearables targeted at consumers interested in tracking fitness, and the collection of personal health information over time. The paper offers an interpretative perspective on runners as performance‐seeking fitness consumers engaged in long‐term self‐management of health. These consumers are driven by a profound motivation to visualise and embody a long‐term state of fitness. Participants were also hyper‐aware of advertising and promotional methods used to engage consumers. The findings raise concerns about the validity of personal fitness data, and how its collection promises improved personal health while visually promoting sought‐after fit bodies. Further research is required to understand the transformative impact of fitness‐tracking and how individuals negotiate personal classifications of health.     

Tuberculosis control: decentralization, local planning and management specificities

The goal was to analyze, according to the perception of health managers, the practices that guide tuberculosis control actions in cities in the metropolitan region of Jo?o Pessoa - PB, Brazil. This qualitative study involved eight professionals in management functions. Testimonies were collected through semi-structured interviews between May and June 2009 and organized through content analysis. Despite the acknowledged benefits of tuberculosis control action decentralization, local planning indicates the predominance of a bureaucratic model that is restricted to negotiation and supplies. Local programming is centered on the coordinator, which shows a command line and vertical management that lead to the fragmentation of the work process. Management action should follow an innovative and transformative route that surpasses bureaucratic barriers and faces the biggest challenge it is proposed: to balance professional interrelations with a view to improving health work performance.     

Religious Faith and Transformational Processes in Marriage

Leading scholars of marital processes strongly recommend supplementing the current focus on marital conflict to include research on transformative processes. This qualitative study examines the connection between religion and the transformative processes of commitment and coping in marriage. The sample for this study includes 184 married couples (N = 368 individuals), making it far larger than most in‐depth, qualitative interview‐based studies. Participants included Christians, Jews, and Muslims with an over sampling of minorities and immigrant families living in all eight regions of the United States. For several decades studies have shown a largely positive correlation between (a) religiosity and marital commitment and (b) religiosity and (generally) positive coping, but with little explanation regarding how and why. Findings of this study indicate that there are specific religious beliefs and practices related to how these couples approach their marriages—including several that relate to the two transformative processes of commitment and coping.     

Gaining control over breast cancer risk: Transforming vulnerability,uncertainty, and the future through clinical trial participation – a qualitative study

Concepts of disease risk and its management are central to processes of medicalisation and pharmaceuticalisation. Through a narrative perspective, this paper aims to understand how such macro‐level developments may (or may not) be experienced individually, and how an algorithm that is used for recruitment into a clinical trial may structure individual notions of being ‘at risk’ and ‘in need of treatment’. We interviewed 31 women participating in the Study of Tamoxifen and Raloxifene (STAR), a chemoprevention trial conducted in the US between 1999 and 2006. Interviews were thematically analysed. Women in the study had experienced the threat of breast cancer and felt vulnerable to developing the disease prior to STAR participation. The diagnosis of ‘being at risk’ for cancer through an algorithm that determined risk‐eligibility for STAR, opened up the possibility for the women to heal. The trial became a means to recognise and collectivise the women's experiences of vulnerability. Through medication intake, being cared for by study coordinators, and the sense of community with other STAR participants, trial participation worked to transform women's lives. Such transformative experiences may nevertheless have been temporary, enduring only as long as the close links to the medical institution through trial participation lasted.     

Pierre Bourdieu and transformative agency: a study of how patients in Benin negotiate blame and accountability in the context of severe obstetric events

This paper explores the social and institutional processes that constrain and enable obstetric patients in Benin to critically evaluate quality of healthcare and to stimulate positive changes in the health system. Based on qualitative data collected as part of a hospital auditing system, the paper analyses semi-structured patient feedback interviews and their function as a primary mechanism through which critical patient evaluation can develop constructively. Using a Bourdieuan framework, we explore the dynamic social conditions that give rise to transformative agency and institutional change. Our results show that hospitals are often permeated with the habitus of employment, kinship and reproductive social fields, through which a number of social, economic and healthcare conflicts, power struggles and blame-inducing interactions emerge. These conflicts generally serve to keep patients quiescent and passive when it comes to developing critical statements of quality of care. In a subset of cases, however, these conflicts are transformed by patients and their family members into opportunities for modifying the values and practices of each habitus in new and creative ways. The active negotiation of social conflict and blame enabled a minority of patients actively to divert blame from themselves and to develop and maintain critical healthcare evaluations.     

Why we need multi-level health workforce governance: Case studies from nursing and medicine in Germany

Health workforce needs have moved up on the reform agendas, but policymaking often remains ‘piece-meal work’ and does not respond to the complexity of health workforce challenges. This article argues for innovation in healthcare governance as a key to greater sustainability of health human resources. The aim is to develop a multi-level approach that helps to identify gaps in governance and improve policy interventions. Pilot research into nursing and medicine in Germany, carried out between 2013 and 2015 using a qualitative methodology, serves to illustrate systems-based governance weaknesses. Three explorative cases address major responses to health workforce shortages, comprising migration/mobility of nurses, reform of nursing education, and gender-sensitive work management of hospital doctors. The findings illustrate a lack of connections between transnational/EU and organizational governance, between national and local levels, occupational and sector governance, and organizations/hospital management and professional development. Consequently, innovations in the health workforce need a multi-level governance approach to get transformative potential and help closing the existing gaps in governance.     

Patient-centered medical homes: will health care reform provide new options for rural communities and providers?

Many are calling for the expansion of the patient-centered medical home model into rural and underserved populations as a transformative strategy to address issues of access, efficiency, quality, and sustainability in the delivery of health care. Patient-centered medical homes have been touted as a promising cost-saving model for comprehensive management of persons with chronic diseases and disabilities, but it is unclear how rural practitioners in medically underserved areas will implement the patient-centered medical home. This article examines how the Patient Protection & Affordable Care Act of 2010 will enhance rural providers' ability to provide patient-centered care and services contemplated under the Act in a comprehensive, coordinated, cost-effective way despite leaner budgets and health workforce shortages.     

Best laid plans: examining contradictions between intent and outcome in a feminist, collaborative research project

This article critically examines a feminist, collaborative research method that was intended to be political in standpoint, gendered in focus, reflexive in process, and transformative in outcome. By incorporating collaborative elements into a qualitative, three-step research design, the author hoped to challenge both what was known about nurses' job displacement and how that knowledge was produced. This article explores the contradictions between the author's best laid plans and the actual process of discovery. Recommendations for future research include considerations about the social and political context in which the research takes place, cautions about gender inclusivity in the research population and analytic frameworks, strategies for encouraging participants' critical thinking, and a caveat with regard to transformative outcomes.     

Embracing the tension between vulnerability and credibility: ‘intellectual candour’ in health professions education

The tension between expressing vulnerability and seeking credibility creates challenges for learning and teaching. This is particularly true in health care, in which practitioners are regarded as highly credible and making errors can often lead to dire consequences and blame. From a transformative learning perspective, expressing vulnerability may help individuals to access different ways of knowing. By contrast, from a sociological perspective, seeking to maintain credibility results in ritualised interactions and these ritualised encounters can reinforce credibility. One means of embracing this tension between expressing vulnerability and appearing credible is ‘intellectual candour’, an improvisational expression of doubts, thoughts and problems with the dual purpose of learning and promoting others’ learning. Educators’ revelations of inner struggles are proposed as a means of inviting reciprocal vulnerability. This builds trust and a platform for learning, particularly of the transformative nature. It also allows modelling of how to balance the vulnerability–credibility tension, which may provide a template for professional practice.     

Intersectionality and the determinants of health: a Canadian perspective

Despite Canada's leadership in the field of population health, there have been few successes in reducing the country's health inequities. There is an increasing recognition that regardless of the progress made to date, significant gaps remain in comprehending fully the root causes of inequities, including the complex ways in which the determinants of health relate, intersect and mutually reinforce one another. Calls are being made to draw on the theoretical insights of critical social science perspectives to rethink the current framing of health determinants. The aim of this paper is to contribute to the theoretical project of population health by exploring the innovative paradigm of intersectionality to better understand and respond to the ‘foundational’ causes of illness and disease, which the health determinants perspective seeks to identify and address. While intersectionality has taken hold among health researchers in the United States, the United Kingdom and Canada, the transformative potential of this approach in the context of health determinants is largely unexamined.     

‘I could never have learned this in a lecture’: transformative learning in rural health education

Health indicators for rural populations in Australia continue to lag behind those of urban populations and particularly for Indigenous populations who make up a large proportion of people living in rural and remote Australia. Preparation of health practitioners who are adequately prepared to face the ‘messy swamps’ of rural health practice is a growing challenge. This paper examines the process of learning among health science students from several health disciplines from five Western Australian universities during ‘Country Week’: a one-week intensive experiential interprofessional education program in rural Western Australia. The paper weaves together strands of transformative theory of learning with findings from staff and student reflections from Country Week to explore how facilitated learning in situ can work to produce practitioners better prepared for rural health practice.     

New disability rights require organizational change and leadership

On July 26, 1990, President George Bush signed the Americans with Disabilities Act (ADA). This legislation has been referred to as the "emancipation proclamation for the disabled" because of its great importance to persons with disabilities in our society. The ADA will not be implemented in a substantive way, however, without truly transformative leadership. Because of their traditional role in this area, health care professionals are in a unique position to provide that leadership and to help effect the necessary organizational changes. Passage of the ADA is only the beginning; the true test of its success will be in its implementation.     

Accessing emergency contraception: the role of friends in the adolescent experience

This paper focuses on the findings of a qualitative study that explored adolescent experiences of accessing emergency hormonal contraception (EHC). It describes how anticipated judgements and associated feelings of embarrassment and shame were dealt with through friendship. The paper outlines how, contrary to the notion of the ‘mean girl’, friends assumed crucial supporting roles which included confidante, advisor, and motivator. In some cases this included physically accompanying hesitant friends to sexual health services. The narrative brought to light how friends often kept each other on the straight and narrow, providing a sharp contrast to the image of irresponsible or shameless adolescents. Being this friend was transformative, offering a kind of reform that allowed a shift from the perceived label of promiscuous risk taker to that of informal advisor and supporter. The study concluded that friends were instrumental in the successful negotiation of the powerful discourses of risk and responsibility in the health arena and that this example of female solidarity at a time of crisis potentially plays a key role in adolescent sexual health.     

Transforming the U.S. child health system

This paper presents a vision and rationale for reform of the U.S. child health system based on paradigmatic changes in the conceptualization of child health development. Reviewing well-known and well-documented accounts of how this system is under-performing, we suggest that a bold, well-defined, transformative, and long-term reform strategy is needed to address intractable problems in the underlying operating logic, organization, and financing of the current child health system. We conclude by considering an optimistic, long-term policy transformation agenda, building up emerging opportunities and changing realities in the United States and abroad.