Building Bridges Between Researchers and Managers: Can It Be Done?

Slide Presentation from the AHRQ 2008 Annual Conference

On September 8, 2008, David R. Nerenz, Ph.D., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (855 KB; Plugin Software Help).

Slide 1

Building Bridges Between Researchers and Managers: Can It Be Done?

David R. Nerenz, Ph.D.
Director, Center for Health Services Research
Henry Ford Health System
Detroit, MI

Slide 2

Henry Ford Health System

• Large, vertically integrated health care system:
  • Hospitals
  • Medical Group
  • HMO
  • Nursing Homes
  • Ancillary Services
• In-house health services research center since 1980
  

Slide 3

The black and white photograph shows a broken, abandoned bridge.

Slide 4

Researchers and Managers—Different Worlds

• Health Services Research vs. Health Care Administration
  • Years to complete and publish typical project vs. answers needed in days.
  • Interested in universal, cause-effect relationships vs. interested in practical, applicable solutions to problems.
  • p <.05 is key vs. p <.30 is fine, if implementable and likely to yield big difference.
  • Faith in universality of phenomena under study vs. "yes, but can it work HERE?"
  • "Management by data", or "evidence-based management" vs. Management by vision, principles, relationships, and incentives.

Slide 5

"All {Quality Improvement/System Change/Relevance of Research Findings} is Local"

• Our experience is shaped by, and dependent on, local circumstances that don't exist in precisely the same way anywhere else.
• Relationships among individuals and organizations are unique—lessons learned may or may not apply elsewhere.

Slide 6

Researchers and Managers—Different Worlds

• Researcher's approach to question of what works better—put two alternatives in a randomized controlled trial (RCT) and run a study (or do an observational study with propensity score analysis...).
• Manager's approach to question of what works better—implement alternative that can be implemented, then work on "tweaking" to improve gradually over time and make it work better.

Slide 7

Significance or Effect Size?

• "Change is painful. The magnitude of difference {for a new approach} has to be around 25%. I won't tear the organization apart for a 10% difference—certainly not 5%."
  —William Conway, M.D., Senior Vice President, Chief Medical Officer, Henry Ford Hospital

Slide 8

Types of Studies that Typically Don't Influence Managers

• Studies of organizational factors.
• RCTs of "big things"—quality improvement, electronic medical records (EMRs), incentive systems.
• Any study whose results are expressed as beta coefficients or odds ratios.

Note: A sample table entitled, "Odds Ratios for Lung Cancer from Active and Passive Smoking Exposure Variables in Mexico City, According to Gender," with data based on both males and females and their smoking habitats (such as smoking status, no. of cigarettes a day, duration of smoking, lifetime cigarette consumption, age started smoking, and passive smoking at home), is also included.

Slide 9

Types of Studies that Influence Managers—I

• Identify, describe, or quantify an important problem:
  • Leape—medical errors
  • Wennberg—small area variation
  • McGlynn—quality of care in primary care settings

Slide 10

Types of Studies that Influence Managers—II

• Studies that develop a tool or a metric or a classification system that addresses a management problem:
  • DRGs (Diagnosis Related Groups—hospital payment)
  • HEDIS (Health Plan Employer Data and Information Set—quality of care measures)
  • ACGs (Adjusted Clinical Groups—severity/risk adjustment)

Slide 11

Types of Studies that Influence Managers—III

• Demonstration or quality improvement (QI) projects that show that something MIGHT work:
  • Hospitalists (Simmer et al)
  • Group visits
  • Cancer care coordination
  • Patient safety initiatives
• Some of these projects may not be research at all—will not produce generalizable knowledge as their primary aim

Slide 12

Examples of Researcher-Manager Collaboration

• Center for Health Management Research:
  • University of Washington, University of California, Health Research and Educational Trust (HRET), 10 health care organizations, 13 other universities
• AHRQ's ACTION (Accelerating Change and Transformation in Organizations and Networks) program
• Veterans Administration Health Services Research (HSR) Centers of Excellence

Slide 13

Building the Bridge to the Other Side—A Different Research Paradigm

• Clinician researchers—those who actually do patient care should be those who design, test, and refine health care delivery innovations.
• Research in clinic and inpatient unit "laboratories"—example—Mayo Clinic's SPARC unit. Research done in organizations, not about organizations.
• Research on truly new things to determine whether they can work, rather than on big, already-implemented things to determine whether they do work (or did work!).
• Focus on managers' problems rather than policymakers' problems—e.g., reducing medical errors, reducing no-shows, enhancing interpreter services, reducing inefficiency and duplication... (industrial engineering).
• Small, bite-size problems rather than large, mega-problems (not, "Do EMRs enhance quality of care?", but 100 specific questions on how to create or enhance an effect of a specific EMR system on quality of care)
• Explicit study attention paid to local context effects and interactions rather than use of randomization designs and regression models to eliminate them.

Slide 14

What We Can Do

The color photograph shows a lit-up, completed bridge.