Improving the quality of care in nursing homes has been a major theme in health care for over 30 years. In this vein, a number of structural and process characteristics of nursing homes have been examined over the years in terms of their relationship with quality. Characteristics such as facility size, ownership, chain membership, facility resources and culture, medical treatments offered, specialized care settings, and percent private pay have all been related to outcomes1–5. While these factors clearly help frame the quality-of-care equation in the nursing home setting, the nature of their relationship to quality has been mixed, at best. Medical staff in nursing homes include the medical director and other attending physicians as well as nurse practitioners and physician assistants who partake in making medical decisions regarding the care of residents. These providers may, or may not have, coordinated or common practice models and standards, which we refer to as medical staff organization. The role played by medical staff organizational factors on nursing home care, has not been systematically examined. The present study seeks to construct and validate a self-report scale to measure the dimensions that characterize nursing home medical staff organization (NHMSO). When validated, the NHMSO dimensions may prove to be a significant factor contributing to the quality of care delivered in nursing homes. This in no way should be construed as detracting from the significant contributions of the nursing staff to overall quality of care. The conceptual basis for NHMSO is presented below followed by a description of survey development and testing.
In conceptualizing organization within a long-term care environment it is important to consider both structural and cultural attributes. With respect to structure, Donabedian’s structure/process/outcome (SPO) model is frequently cited in research on measures of healthcare quality6. Donabedian defined structural measures of quality as the professional and organizational resources associated with the provision of care, such as staff credentials and facility operating capacities. Contingency theory also considers organizational structure, viewing effective organizations as having structures that both support the unique nature of their production process (technology) and are customized to complement their environments7. However, contingency theory departs from the SPO model in the conceptualization of structure. While the SPO model views structure in terms of capacities and capabilities, contingency theorists include strategic dimensions reflecting the organization’s choice of mechanisms for communication, coordination and integration of effort across the organization. The elements of structure identified in contingency theory include formalization, specialization, standardization, complexity and centralization. Formalization is the amount of written documentation in the organization, including procedures, job descriptions, regulations and policy manuals. Specialization refers to the degree to which tasks are subdivided into jobs, while standardization is the extent to which similar work is performed in a uniform manner. Complexity is the number of discrete units and their arrangement in the organization. Organizations that array units in a descending hierarchy are vertically complex, while organizations with many units operating on the same level are horizontally complex. Finally, centralization refers to the level at which decision making authority is granted. An organization in which all decisions are made by top management is highly centralized. Taken in the aggregate, organizations high on these dimensions evidence more bureaucratic control.
Thus, the two theories present different but highly complementary perspectives on the salient characteristics of organizational structure8. While the SPO paradigm focuses on measures of organizational capacity and capability, contingency theory focuses on the mechanisms for communication, coordination and control.
Culture differs from structure in that while structure is usually explicit and visible within organizations, cultural attributes are often implicit and unobservable. Organizational culture consists of values, guiding beliefs, understandings and ways of thinking shared by members of the organization. Cultural attributes display themselves in many ways but typically evolve into a patterned set of activities carried out through social interaction. The point here is that these social interactions are the vehicle for communication, coordination and integration of activities. Finally, medical staff organizational characteristics can be expected to vary in response to differences in nursing home structural and cultural characteristics, the context in which the medical staff operates.
The conceptual framework described above has been adapted to the study of medical staff organization in acute hospitals. Roemer and Friedman9, in their classic and still seminal article, defined seven dimensions that could describe medical organization in hospitals: staff composition; appointment process (i.e.extant procedures to appoint the practitioner to the medical staff and permit him/her to practice medicine); job commitment of physicians; reporting and coordination systems; number of control committees; documentation and informal interpersonal relationships. They found that these organizational dimensions were related to quality of care. Specifically, hospital performance, as measured by national accreditation, was related to the aspects of the physician’s job commitment and the more tightly structured hospital staff organization. Results from Shortell, Becker, and Neuhauser 10, and Flood and Scott11, further suggest that structured medical staffs have better medical/surgical outcomes. The Shortell and LoGerfo’s12 study of 96 mid-Western hospitals found that medical staff organization characteristics such as involvement of medical staff and percent of active staff on contract were all associated with outcomes, independent of hospital and individual characteristics. These studies suggest that quality of care is related more to how physicians interact as a professional group and the extent of their ties to the institution than the individual characteristics of the physician. More recently, Shortell, Schmittdiel, and Wang13 extend this logic to medical groups delivering chronic care in the outpatient setting. They have demonstrated that internal organizational factors (i.e., resource acquisition, resource deployment, and commitment to a quality centered culture) differentiate between high and low performing medical groups.
Distinct from the acute and outpatient settings, the nursing home environment is unique. This creates the need for an effective translation of medical organizational theory to the long term care setting, which is the focus of the following study approved by the University of Rochester IRB.