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With medical evidence constantly advancing, the health care system faces pressure to generate, apply and integrate innovations to improve the quality of patient care. This dissertation examines how organizational characteristics influence these processes. The first study, a systematic review, investigates how organizational features influence the translation of basic research findings to clinical applications. Results showed a dearth of peer-reviewed literature on this topic, despite a proliferation of efforts to accelerate translational research by manipulating organizational structures and processes. Few studies effectively linked structures, processes and outcomes and no organizational feature was associated conclusively with translation of research into clinical practice. The second study draws on in-depth qualitative interviews (82 participants at 10 hospitals) to understand how hospitals that reduced readmission rates had applied innovations in clinical practice and organizational context. High performing and low performing hospitals had both implemented similar clinical practice changes in their efforts to reduce readmissions; however, high performing hospitals reported greater investment in creating an organizational context to facilitate readmissions. This included more extensive efforts to improve collaboration within the hospital, greater coordination between the hospital and outside providers, deeper engagement in learning and problem solving related to readmissions, and greater senior leadership support. The third study draws on an expanded set of interviews from the same data collection (90 participants at 10 hospitals) to investigate mechanisms through which innovations become integrated into hospital routines. Despite a well-developed literature on the initial implementation of new practices, we have limited knowledge about the mechanisms by which integration occurs. Results showed that when an innovation was integrated successfully, a small number of key staff held the innovation in place for as long as a year while more permanent integrating mechanisms began to work. Innovations that proved intrinsically rewarding to staff integrated through shifts in attitudes and norms over time. Innovations that did not provide direct benefits to staff were integrated through changed incentives or automation. Together, these studies illuminate opportunities for hospitals to improve patient care by managing the organizational context in which innovations are deployed. Understanding how organizational context affects translation requires further research. / 2017-10-02T00:00:00Z

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The purpose of this study was to identify, through a needs analysis, the skills required of the clinical supervisory role in certified home health agencies as described in the literature and as perceived by clinical supervisors and agency administrators. The identified skills were then used to propose elements for a training curriculum. The general problem guiding this research is the lack of a systematic approach to supervisory training and development in certified home health agencies in Massachusetts that may result in supervisory employees being inadequately prepared to assume the responsibility of that role. A descriptive survey design was utilized. A questionnaire was mailed to first-line clinical supervisors and their administrators to assess the skill requirements of the supervisory role as perceived by these respective groups. The sample survey, which consisted of 125 certified home health agencies, was obtained from the Massachusetts Department of Public Health. The response rate was 63% for the administrators and 65% for the supervisors. A modified version of the conceptual framework of the needs identification process as presented by Watson (1979) was utilized in conducting the analysis, and the skills were categorized using Katz's model (1974) of conceptual, technical, and human competencies. The findings of the analyses showed that the administrative respondents perceived a greater need for the skill development of their supervisors in all three areas of conceptual, technical, and human skills than the supervisors perceived for themselves. In addition, supervisory respondents with 6-10 years of professional experience and those with over 21 years of supervisory experience reported the greatest need in all three areas. The findings also showed that the majority of incumbent supervisors in certified home health agencies were technically at an entry-level stage of management, and that the combined responses of both the administrative and supervisory respondents supported the need for additional training in the technical and human skill areas. As a result, the concluding recommendations for curricula development for training programs for incumbent and future clinical supervisors were focused on those skills specific to the technical and human competency areas as described in the study.

Local context should be considered a significant social determinant of health for immigrant communities, particularly those with precarious legal status. In this thesis I use a study done by Lilia Cervantes, MD and collegeaues of undocumented immigrants with end-stage renal disease attempting to access healthcare in three different US states to expand on my argument. Due to the lack of comprehensive federal immigration reform since 1986, many immigrants depend on the Emergency Medical and Active Labor Treatment Act (EMTALA) to access healthcare, which provides emergency-only care. Without federal mandates, further healthcare for this population is dependent on local laws and/or safety-net services. As a result, this local context impacts their medical outcomes, healthcare utilization and economic costs and acts as a potential moral hazard to family, patients and providers of and serving immigrant communities. / Urban Bioethics

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