Community hospitals accomplished the time-sensitive transfer of AMI patients through routinization. The transfer routine involved cueing of a recurrent, stable and collective work process. This was true of the overall approach to the work of transferring STEMI patients, and for the micro-decision of destination selection. Nationwide quantitative data reinforced that the processes seen at these three sites may be generalizable to the US system as a whole. Although physicians were nominally the decision makers in patient transfers, participants at our field sites believed that revenue-maximization efforts by hospitals and insurance companies channeled patients to preferred destinations. Due to the primacy afforded to financial considerations, routinization was achieved alongside the exclusion of some information from the decision-making process, notably patient preferences and published hospital quality data.
This study is among the first to describe work routinization as a key organizing factor in patient transfers, pointing to a scarcely documented form of social order in health care. As described, a routine approach to care organization offered many benefits, including speed, uncertainty reduction and coordination. Our research, however, points to important tradeoffs that result as routinization increases, regardless of whether written protocols are used (e.g., Gawande, 2010
). A focus on speed may mean that community hospitals do not use new information about hospital quality, and they may thus send patients to lower quality hospitals. Differences in rigorous death rate quality metrics suggest that this may decrease their likelihood of survival.
Moreover, such a routine process gives patients little opportunity for patients to state a preferred destination. Although involvement of acute AMI patients in decisions is challenging because they may be in pain, distressed, or sedated, there is an ethical and legal obligation to obtain informed consent while balancing the need for speedy treatment (Levine et al., 2011
). Patient or proxy consent is routinely obtained before interhospital transfer or PCI is performed in clinical practice; many recent STEMI trials obtain full written informed consent as a part of their time-sensitive enrollment practices (Foex, 2004
). We argue that, given its clinical gravity, transfer destination quality information should be included in these mandated informed consent discussions. This appears feasible since some AMI patients wish to participate in decisions about their care, even in emergency situations (Decker et al., 2007
). Because informed consent to participate in a clinical trial is more demanding and time consuming than choosing a transfer destination based on quality, we believe that precedent shows the plausibility of patient participation in this important decision.
Our findings suggest that there is a need to revisit the assumptions of US federal policies mandating the provision of hospital quality information. These policies assume that by providing quality information and aligning incentives, patients and purchasers will be empowered to select better care, thus stimulating hospitals to compete on care quality. Our findings, however, suggest that this agenda is based on an unrealistic model of health care work in two ways. First, the patient transfer process provides an example of the institutional embeddedness of the health care market (e.g., Scott, Ruef, Mendel, & Caronna, 2000
). The set of hospitals to which a patient may be transferred is not simply the set of capable hospitals within a given geographic locale; previous, established relationships determine which destinations are considered possibilities, and that limitation of the choice set does not occur primarily on the basis of quality (Lomi & Pallotti, 2012
). With greater routinization, destinations are not so much selected as they are automatically triggered. Therefore, there is little opportunity for a countervailing personal push for quality (based on publicly reported outcomes) to balance institutional structures focused on goals other than patient outcomes. Effective competition between health care organizations cannot be assumed nor achieved through simple provision of information.
Our research suggests that patient transfer destination selection is more an issue of priorities than information. Competition for revenue results in strategic moves to channel patients to preferred destinations — a key form of market advantage. Community hospitals may also undermine perceived competitors by refusing to transfer to them, as at Site Three. Hence, a shift toward more quality-focused patient transfers would necessitate hospital redefinition of the problem as one of clinical (rather than simply financial) import. One informatics-based strategy to do so might be to incorporate patient transfers into clinical decision support systems (CDSS), rather than simply making information available on a public website. One benefit of such an approach would be greater integration of patient transfers into the care process. However, disadvantages to this approach include distance from the manual processes in some hospitals (such as our Sites One and Three) and difficulties surrounding information sharing across organizations. Accordingly, it is unlikely to be enough to simply design an informatics solution and hope for the best. Indeed, changes that field sites had already made to their STEMI patient care processes (such as rapid EKGs for chest pain patients) resulted from both Medicare reimbursement pressures and national quality campaigns. As Heimer (1999)
argues, national guidelines were “domesticated” through incorporation into organizational routines. Thus, organizational change would require proactive strategies to undo established routines and create new ones — routines that incorporate current hospital quality information, as well as new information that is available annually. Such establishment of new routines would be optimally pursued through training and job design, while establishing controls for critical steps in the process (Pentland & Feldman, 2008
). From a policy perspective, such controls might be provided by incentives for quality-driven patient transfers — perhaps through new Medicare reimbursement strategies. Broadly, then, there is a need to develop a socio-technical
system (Coiera, 2007
) for patient transfers — a system in which organizational processes support the use of technologies containing care quality information, and vice versa.
Several limitations of this paper should be noted. We conducted interviews at three purposively selected community hospitals in the US; additional perspectives may be present in other settings. Additionally, aside from data gathered from Medicare records, we cannot ascertain the generalizability of observed phenomena to the population of community hospitals. We also heavily interviewed nurses, given the prominent role they play in patient care at community hospitals and their central perspective on the work of hospitals; other providers may offer different views. Complementary data from direct ethnographic observation could determine whether actual behavior varies from the self-reported behavior reported here.
In sum, this study documented the revenue and relationships at stake in AMI patient transfer decisions, as well as the routine nature of the work process. Observed characteristics of the patient transfer process provide insight into why community hospital staff may little value objective hospital quality information. Our research therefore provides a portrait of the barriers that would be faced in attempting to shift transfers to a more quality-driven and patient-centered process. Accordingly, we should anticipate that such changes would be controversial and meet with institutional resistance. Consequently, efforts to promote quality-driven interhospital patient transfers should be re-conceptualized as a complex process that will require sustained health policy and organizational change efforts, as well as informatics.