Determinants and Effects of Organizational Strategies of Control Directed At Quality of Care in Organized Ambulatory Care Settings.
Wyszewianski, Leon
1980
Abstract
A commonly used method for evaluating the quality of medical care services is to determine whether certain representative or critical clinical tasks and procedures were performed (for example, whether the patient's blood pressure was measured and recorded at a hypertension follow-up visit). When deficiencies using this assessment method are found in a clinic, the clinic chief and others responsible for overseeing the delivery of health services can be expected to consider taking administrative actions to correct the deficiency, as well as to prevent other, similar deficiencies from occurring. However, little is currently known about the effectiveness of such administrative actions and policies. This study was conducted to determine how and to what extent the performance of selected clinical tasks in outpatient clinics is affected by organizational "strategies of control," that is, administrative policies and practices designed to ensure that a given task, or a category of tasks, is performed. The design of the study incorporates concepts and hypotheses drawn from the organization theory literature about the relation between technology, structure, and performance. The specific objective of the study was to determine: (1) what factors influence the selection of strategies of control directed at the performance of given tasks, and (2) to what extent performance or nonperformance of clinical tasks is influenced by congruence, or "consonance," between, on one h and , strategies of control directed at task performance and , on the other, the characteristics of the task and the attitudes of the clinic's staff about the strategies themselves. The study focused on eleven clinical tasks associated with five common conditions or diagnoses in internal medicine, gynecology, and pediatrics. Data were obtained from sixteen outpatient clinics in five delivery sites located in two counties in the Midwest. Task performance data, obtained from another, concurrent study on the assessment of ambulatory care, were supplemented with interviews of clinical personnel to obtain information on the presence of organizational strategies of control and on staff attitudes about strategies of control and about the tasks themselves. The strategies of control directed at tasks fell into two categories: (1) bureaucratic strategies of control (including "reminder" forms, explicit policies, and assignment of task performance to a specific person), and (2) feedback controls (supervision, formal audits, and rewards and disciplinary actions). It was hypothesized that the more a task is routine the more likely it is for bureaucratic strategies of control to be directed at that task; the findings suggest instead that task routineness is a necessary but not sufficient condition for the presence of bureaucratic strategies. Similarly, it was found that the "consonance" or fit between task routineness and bureaucratic strategies is a sufficient but not necessary condition for high performance. That finding is consistent with the notion that, while high performance on routine tasks can be achieved through bureaucratic strategies of control, other factors and mechanisms can yield equally good results for such tasks. No support was found for the hypothesis that the presence of feedback controls is related to the visibility of the task. That result, however, can be attributed to the low variability in the measures used for testing the hypothesis. The attitudes of those who perform tasks and the decisions made by clinic chiefs reflected a strong awareness that bureaucratic strategies of control are appropriate only for routine tasks. At the same time, however, clinic chiefs did not see it as imperative that bureaucratic strategies be directed at every routine task; rather, for such tasks they perceived bureaucratic strategies of control as only one of the optional mechanisms available for achieving high performance.Types
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