Prelims

Introduction

The 20th volume of Advances in Health Care Management (AHCM) showcases the value of health-care managerial and organizational research as a tool for furthering understanding of grand health-care challenges: what they are, why they exist, the consequences that they have, and what can be done to address them. The importance of advancing this understanding has never been so salient as in the current health-care landscape, though the reality is that grand challenges have always characterized health care. Organizational scholars define grand challenges as large, unresolved problems (Colquitt & George, 2011; George, 2014). “Grand health-care challenges” include current events such as the COVID-19 pandemic, as well as ongoing challenges related to achieving the quadruple aim of health care: improving the health of populations, reducing the cost of health care, improving patient care experiences, and improving the experience of working in health care (Sikka, Morath, & Leape, 2015). This volume demonstrates that these challenges are amenable to organizational and managerial solutions, and therefore health-care managerial and organizational research has many important lessons to contribute.

Many health-care challenges have become even grander, more perturbing to understand and address, because they interact with one another in complex ways. Grand challenges, however, are not only characterized by their complexity. Scholars have observed that these problems have three characteristics: (1) complex, nonlinear interactions; (2) radical uncertainty – leading to the need to make decisions in a state of ambiguity; (3) and an evaluative nature – meaning the definition of the problem itself depends on one's position in society, which can cause conflict among stakeholders about goals and solutions (Ferraro, Etzion, & Gehman, 2015). Each of these characteristics is formidable for health-care organizations (HCOs: e.g., hospitals, urgent care centers, community health centers, primary care practices, long-term care facilities, state and local public health departments), which already struggle to manage care and operations for diverse patients through the efforts of diverse providers, staff, and administrators. Often occurring together, these characteristics pose an even more daunting situation for HCOs. They cause difficulty gaining a productive understanding of grand problems. They also cause the need for organizations and the industry as a whole to implement multifaceted solutions that reflect both the grandness of the challenges and the complex adaptive system that is an HCO (Begun & Jiang, 2020).

It is well accepted that grand challenges require “the pursuit of bold ideas and the adoption of less conventional approaches to tackling large, unresolved problems” (Colquitt & George, 2011, p. 432; see also; George, 2014). An area of debate remains: what can or should be leveraged to develop insight and solutions for these challenges? This volume proposes and demonstrates the utility of leveraging managerial and organizational science – both theory and research methods – to address grand challenges for HCOs and in health-care management. In that regard, it mirrors the message of a recent review on organizational science and health-care research (Mayo, Myers, & Sutcliffe, 2021), and builds on prior work that has presented lessons derived from management research for responding to grand challenges such as COVID-19 (Nembhard, Burns, & Shortell, 2020), innovation implementation failure and poor quality of care (Nembhard, Alexander, Hoff, & Ramanujam, 2009), collaborative practice (Dow, DiazGranados, Mazmanian, & Retchin, 2013), and ensuring compassionate care systems (Vogus, McClelland, Lee, McFadden, & Hu, 2021). While that work has not been empirical, it has shown the potential for organizational and managerial research to inform the handling of challenging issues in health-care management. This volume takes the next step by highlighting additional grand health-care challenges, labeling them as such, and offering empirical research that tackles these challenges.

The Publication of This Volume During the Global COVID-19 Pandemic is Not a Coincidence

This pandemic shed light on weaknesses in national and global health-care systems and reminded us what a grand health-care challenge looks like, for all the world to see. To the extent ongoing challenges had become normalized, COVID-19 reinvigorated concern about them due to its intersection with them. During this time of undeniable challenge in scope and impact, we felt compelled to adopt the focus and frame of “grand health-care challenges.” Foci and frames are important because they guide attention and action (Russo, Schoemaker, & Russo, 1989). While the field of health-care management recognizes that there are many grand challenges, they are rarely discussed using this frame. A search of PubMed in June 2021 with the terms “grand challenge” or “grand challenges” in the title or abstract and “health care-management” and “organization” in any search field resulted in only two relevant articles, one related to chronic disease management (Lee & Ho, 2019) and one related to information technology use (Detmer, 1997). This volume aims to change that and usher creativity in questions, theorizing, methods, and solutions, more likely if grand challenges are framed as such (Colquitt & George, 2011; George, 2014).

Overview of the Papers in This Volume

The following 10 chapters share insights and actionable findings for health-care management related to five grand challenges currently facing the health-care sector: (1) caring for vulnerable populations; (2) maintaining the health-care workforce; (3) translating innovation into practice; (4) sustaining organizations; and (5) navigating pandemics. Each challenge is discussed in its own section and addressed by two chapters that offer different perspectives and approaches to the challenge. Readers may disagree with our chapter-challenge categorization, correctly noting that a chapter also addresses other challenges within this volume. We chose to focus on the primary challenge highlighted by the authors. Nonetheless, the multiplicity observation supports the argument that there are interactions among grand health-care challenges.

Section 1 includes two chapters about the challenges the health-care sector faces caring for vulnerable populations, which refers to groups and communities at higher risk for poor health as a result of barriers that they experience due to social, economic, political, and environmental resources, as well as limitations due to illness or disability (Mechanic & Tanner, 2007; Waisel, 2013). These populations include those of low socioeconomic status, racial and ethnic minorities, unemployed, uninsured, and the elderly. The elderly are a growing vulnerable population, with people ages 85 and over being the fastest growing segment of many national populations (National Institute on Aging, 2007). While our aging population is a testament to advances in modern science and technology, this trend is associated with a concomitant increase in the disabilities caused by age-related chronic diseases. Vulnerable elderly patients with multiple chronic conditions are straining the capacity of health care and social services systems – the issue addressed by the chapters in this section. In Chapter 1, Zimpel-Leal considers the growing demand for in-home care for the elderly, often referred to as homecare, and presents an ethnographic study of four distinct models of homecare that are shaping the market in England. These models include major innovations that focus on client well-being as an outcome, client choice, and personalization, the homecare workforce as a major stakeholder, and building networks of partners offering access to complementary services, investments, and specialist knowledge. Chapter 2 by Brewster also considers partnerships as a solution to the problem of caring for the vulnerable, specifically focusing on aligning the health care and social services sectors for vulnerable patients with multiple chronic conditions. The work presented in this chapter identifies three major functions of interorganizational relationships and presents practical suggestions for initiatives to promote regional alignment among health care and social services organizations. The solutions presented in these two chapters require integration of the health care and social services sectors, and as such, reflect the complexity of the challenge of caring for vulnerable populations. They also offer direction for addressing this challenge.

Section 2 considers the challenge of maintaining the health-care workforce, including problems of retention and equity. This challenge speaks to the fourth element of the quadruple aim for the health-care sector: improving the work experience. The current state of work experience is a “threat to safe, high-quality care” (National Academies of Sciences, 2019; Prasad et al., 2021). Since 2019 (prepandemic), more than half of the health-care workforce across settings and specialties in the United States (US) report negative work experiences and subsequent burnout due an imbalance between job demands and job resources (National Academies of Sciences, 2019; Prasad et al., 2021). The pandemic is believed to have maintained or exacerbated this imbalance, causing greater concern about much-discussed workforce shortages due to departures from the field. Likewise, inequity in treatment and lack of workplace inclusivity are contributing to departures of talented leaders, clinicians, and staff (Kalina, 2019), raising the importance of figuring out how to improve work experiences and thus maintain the workforce. Research suggests the demands-resources imbalance and poor treatment effects can be addressed by taking a system's approach to solutions, working to improve workforce engagement and workforce safety (Sikka et al., 2015). In this approach, the system refers to the structure and culture of a health-care setting and as such, is a responsibility of health-care management. Both chapters in Section 2 consider the role of health-care management in structural and cultural solutions, one to increase equity (a treatment that affects work experience) and the next to improve retention (an outcome often dictated by work experience). Chapter 3 by Moore, Dishman, and Fick explores operational succession planning as a managerial structure health-care management could employ to reduce employee turnover. Among a national sample of US medical practices, they found that practices engaged in a succession planning process reported significantly lower employee turnover. In Chapter 4, Stephenson and colleagues report on a survey of women physicians, leaders, and faculty in academic medicine environments. Their results show the culture of gender bias that women face in the field of medicine. Based on these findings and the organizational literature, they present recommendations for managers endeavoring to improve the culture of gender equity and inclusivity, and thus address the challenge of maintaining the workforce.

The chapters in Section 3 address the challenge of translating innovation into practice. Successfully responding to the rapid pace of innovation in health care requires developing flexible institutions and processes that can adapt to constant change. On the frontline of health-care delivery, two big areas of innovations are technology (e.g., new health information technologies and personalized medicine) and organizational design and reimbursement (e.g., vertical integration and value-based reimbursement) (Avgar, Eaton, Givan, & Litwin, 2020). The slow pace of innovation implementation and the failure of various initiatives indicate that translation is a grand challenge. The emergence of the field of implementation science, with associated conferences, journals, and federal grant opportunities, is further evidence that translating health-care innovations into practice requires special attention. The consequences of not solving this challenge are interwoven with the grand challenges highlighted in Sections 1 and 2. For example, retaining a diverse and equitable workforce requires successful adaptation to innovations, so as to not contribute to the high rate of job burnout. Additionally, health-care leaders must solve the challenge of translating innovations into practice to successfully care for vulnerable populations. In Chapter 5, Litwin presents a review of the potential of technological change in health care to impact frontline care delivery and outlines prescriptions for managers and policy makers. Chapter 6 by Gregory and colleagues considers methods of effective workforce training as a key solution to this grand translation challenge. The authors present a model of training motivation that identifies factors that can enhance employee engagement in training and retention of knowledge.

Section 4 tackles the challenge of organizational sustainability. To be sustainable in the current health-care environment of constant innovation and change, HCOs must deliver on the quadruple aim (Ramirez, West, & Costell, 2013). Research has demonstrated that key facets of health-care management – board dynamics, ownership structures, and management practices – are central to the process of achieving high performance and sustainability (Lega, Prenestini, & Spurgeon, 2013). The chapters presented in Section 4 expand upon how these facets can influence sustainable organizations. Chapter 7 by La France and colleagues uses a matched-case comparison to explore how hospital ownership can influence the financial stability of a health-care system. Comparison of a private equity-owned system and a nonprofit, religious based system reveals two opposing financial stories, with the private-equity owned system focusing on a “debt-driven explosive expansion” and the nonprofit system engaging in a more measured and methodical merger and acquisition strategy – leaving them in a better financial position across the years and casting doubt on the conventional wisdom that for-profit ownership leads to better financial performance. In Chapter 8, Garman and colleagues present a case study of the National Center for Health Care Leadership's “Best Organizations for Leadership Development” program. This program consists of a bi-annual survey of HCO leadership practices with benchmarking and feedback. This study presents leadership development as an important enabler of adaptive change and thus organizational sustainability.

Section 5 features two chapters that consider the challenge of pandemics for patients, workers, and health-care practices. COVID-19 is the type of pandemic experts have been warning about for decades (Howard-Grenville, 2020), and it has exposed structural challenges in the US health-care system including supply chain issues, work force shortages, and deep inequities and racial biases (Slavitt, 2020). Scholars have deemed COVID-19 a “wicked problem” because there are no proven solutions that can guarantee resolution (Nembhard et al., 2020; Schiefloe, 2020). A survey of hospitals' experiences responding to COVID-19 conducted by the US Department of Health and Human Services identified common coping strategies including: (1) adjusting processes to manage patient flow and facility capacity and (2) ensuring adequate staffing and support staff (Grimm, 2020). The chapters in this section provide context around these two strategies. Chapter 9 by Singer and colleagues presents the results of a survey of US primary care practices which reveals that practices indeed adjusted patient care processes, but the level and perceived success of the changes was associated with practice and payor characteristics. Given these findings, the authors highlight the need for collaborative advantage, that is, collaboration and coordination between administrative actors and across organizations, which others have proposed as the only way to begin addressing a wicked problem (Schiefloe, 2020). In Chapter 10, Fleuren and colleagues address the strategy of ensuring adequate staffing and support staff. They consider the psychological burden of COVID-19 in the health care workforce and present management strategies for HCOs to address this issue, instead of focusing on increasing the resilience of individual workers. Thus, these papers not only offer greater insight on the nature of the pandemics as a health-care management challenge but also strategies for addressing specific elements of this challenge.

Conclusion

A recent article by Nembhard et al. (2020) in NEJM Catalyst Innovations in Health Care Delivery – with COVID-19 as its focus – identified lessons from the management literature for addressing grand challenges, presented as five actions that HCO leaders can take: put people first, manage operations creatively, attend to teamwork and communication, create outside partnerships, and embrace clear and humble leadership. “Put people first” refers to putting the well-being of frontline workers at the forefront of health care delivery to create positive, supportive work environments for them, and ultimately patient care. “Manage operations creatively” requires embracing HCOs as a complex adaptive system and adopting a learning mindset. “Attend to teamwork and communication” is the act of focusing on building structures and processes that support effective relationships among team members. “Create outside partnerships” highlights that grand challenges can only be solved by working across sectors not just within, and lastly HCO leaders must “embrace clear and humble leadership” in order to lead their organizations through complex times and issues. These authors note that the actions they propose can lay the foundation for more agile HCOs. However, there is a need for further explication about how health-care leaders can take these five actions within their organizations, a gap that this volume begins to fill through its chapters.

The 10 chapters in this volume propose solutions that can be categorized into these five actions. For example, Chapter 4 by Stephenson et al. and Chapter 10 by Fleuren et al. propose solutions that “put people first” to address gender bias in medicine and workforce burnout during COVID-19, respectively. The solutions discussed in Chapters 1, 5, and 7 could be categorized as actions to “manage operations creatively.” However, we chose to organize the chapters around grand challenges because we deem it important that we not lose sight of the challenges, nor focus on solutions without consideration of challenges. Moreover, we observe that organizing by challenge has the virtue of allowing for potential breakthrough observations about how similar and different challenges are, and the applicability of solutions across challenges, with some adaptation.

By issuing a call to focus on grand health-care challenges, our intent was and is to catalyze deeper dives into intractable problems in our health-care systems that embrace the complexity of these problems and to highlight opportunities to identify synergies and leverage insights across challenges. To solve these challenges, there is a need for more robust studies, more experiments of potential solutions, and more application of organizational theory and health-care management research. This volume is an important step in that direction and achieves the mission of AHCM to continue the drive toward meeting the grand challenges in HCM by being an outlet for rigorous, practice-relevant research. We look forward to the additional research and effort focused on health care's grand challenges that are sparked by this volume.

Jennifer L. Hefner

Ingrid M. Nembhard

Editors