Collaboration between service professionals during the delivery of health care: Evidence from a multiple‐case study in U.S. hospitals

• Author: Peter T. Ward,Aravind Chandrasekaran,Claire Senot
• Published date: 01 March 2016
• DOI: http://doi.org/10.1016/j.jom.2016.03.004
• Date: 01 March 2016

Collaboration between service professionals during the delivery of

health care: Evidence from a multiple-case study in U.S. hospitals

Claire Senot

a

,

*

, Aravind Chandrasekaran

b

, Peter T. Ward

b

a

A.B. Freeman School of Business, Tulane University, 7 McAlister Dr., New Orleans, LA 70118, USA

b

Fisher College of Business, The Ohio State University, USA

article info

Article history:

Available online 6 April 2016

Accepted by Mikko Ketokivi

Keywords:

Case study

Professional services

Health care delivery

Cross-level collaboration

Formal and informal integration

mechanisms

abstract

We investigate service delivery in one specific type of professional service firms (PSF), namely hospitals.

A distinctive operational feature of this setting is that the delivery of health care services requires

continuous collaboration between two professional workforces: physicians and nurses. We conducted a

multiple-case study at five acute care U.S. hospitals, which involved 49 semi-structured interviews, to

uncover the organizational mechanisms that facilitate effective collaboration between physicians and

nurses. Our analyses suggest that they experience distinct challenges that prevented collaboration during

health care delivery. Specifically,physicians typical ly favoredevide nce-based standards of care which can

sometimes undermine patient interactions. We refer to this preference as a disease-focus challenge. We

also found that nurses were often hesitant to speak-up during their interactions with the physicians,

which constitute a hierarchical challenge. Commonly prescribed mechanisms, such as multi-disciplin ary

rounding, were not effective in overcoming these challenges. Our analyses revealed new forms of

collaboration between different levels of the physician and nursing entities, which we denote as

“nursing-led cross-level collaboration”and “physician-led cross-level collaboration”. Our study suggests

that nursing-led cross-level collaboration helped mitigate the disease-focus challenge experienced by

physicians while physician-led cross-level collaboration helped mitigate the hierarchical challenge

experienced by nurses. It also offers preliminary insights on how PSF in general can develop and sustain

such collaboration. Taken together, our findings offer new insights on the micro-foundations of work

performed by PSF.

©2016 Elsevier B.V. All rights reserved.

1. Introduction

In recent years, scholars have shown a lot of interest in studying

the operational challenges experienced by professional service

firms (PSF) (Greenwood et al., 2005; Williams and Nersessian,

2007; Lewis and Brown, 2012). A vast majority of this research

defines PSF as firms whose operations primarily depend on the

complex technical expertise or knowledge intensity of their

workforce (Von Nordenflycht, 2010). This definition has resulted in

firms from a variety of industries such as accounting, law, adver-

tising, banking, IT, management and engineering consulting, hos-

pitals, and universities to be grouped together as PSF. Deriving a

common understanding on the functioning of PSF by studying such

a diverse group of industries can be a daunting task. As a result,

recent studies on PSF have further characterized them based on

dimensions such as their level of capital intensity, and their

dependence on professional workforce (Von Nordenflycht, 2010).

Such characterization can help researchers take a more granular

approach and advance theories on the micro-foundations of work

performed in PSF.

The purpose of this research is to extend this line of enquiry by

investigating the functioning of one specific type of PSF, namely

hospitals. Like all PSF, hospitals rely on high levels of knowledge

intensity (Alvesson, 2000), i.e. complex knowledge held by the

individual professionals who deliver the care. However, hospitals

also exhibit a number of characteristics that makes their operations

somewhat different from other PSF and warrant more granular

investigation. For instance, in terms of interactions with the con-

sumers, hospitals' patients have a unique and diverse set of needs

both in terms of severity ee.g. common cold vs. heart attack eand

chronicity ee.g. simple fracture vs. long-term heart failure. Process

*Corresponding author.

E-mail addresses: csenot@tulane.edu (C. Senot), chandrasekaran.24@osu.edu

(A. Chandrasekaran), ward.1@osu.edu (P.T. Ward).

Contents lists available at ScienceDirect

Journal of Operations Management

journal homepage: www.elsevier.com/locate/jom

http://dx.doi.org/10.1016/j.jom.2016.03.004

0272-6963/©2016 Elsevier B.V. All rights reserved.

Journal of Operations Management 42-43 (2016) 62e79

variability is also compounded by external constraints such as

payment structures (Medicare, Medicaid vs. other insurers) which

results in hospitals having to, on a case-per-case basis, adapt pro-

cesses to satisfy the requests of multiple customers including pa-

tients, federal agencies, and private insurances. Thus findings from

existing literature that process variability in PSF are mostly due to

“professional preference(s), rather than customer interaction/cus-

tomization or external constraints”(Lewis and Brown, 2012: p.9)

may not be entirely true in hospitals. In the midst of this constant

requirement for adaptation, a particularly salient aspect of hospi-

tals' operations is the need for continuous collaboration between

two distinct professional workforces, namely physicians and

nurses. Although other PSF such as architectural firms also rely on

different professional workforces (e.g. architects vs. structural en-

gineers), the relentless pressures and previously identified

distinctive challenges associated with treating acutely ill patients

can heighten the collaboration challenges among health care pro-

fessionals. Both physicians and nurses have unique skills which are

complementary in the delivery of health care. For instance, physi-

cians' education focuses on the treatment of diseases (Hojat et al.,

2002; Levinson et al., 2010; Wen and Kosowsky, 2013) and their

skills are well aligned with the close monitoring of evidence-based

standards of care. We use the term conformance quality to repre-

sent hospital's level of adherence to these standards of care as

documented on patients' medical records (Senot et al., 2016a). On

the other hand, nurses' education is more holistic in approach. It

includes clinical training but also elements such as patient's overall

wellness and community-based service learning which facilitates

“a sense of caring for others”and the “learning about cultural di-

versity”(Callister and Hobbins-Garbett, 2000: p.178). Thus, nurses

are often better equipped than physicians to interface with the

patient during the delivery of care. We define experiential quality

as the level of interaction between the hospital's caregivers and

patients during health care delivery, as experienced by the patient

(Chandrasekaran et al., 2012).

Studies show that synergies exist between conformance and

experiential quality in terms of reducing readmission rates (Senot

et al., 2016b) and improving patient satisfaction (Chandrasekaran

et al., 2012). Noting these synergies, the Centers for Medicare and

Medicaid Services (CMS), a public regulatory entity which covers

the majority of patients in U.S. hospitals, changed their reim-

bursement policy, thereby setting the tone for all other payers.

Beginning October 2012, U.S. hospitals are at risk of losing 1% of

their pre-determined reimbursement rates for CMS patients if they

do not show sufficient levels of conformance and experiential

quality (cms.gov), with this penalty increasing to 2% by 2017. An

apparent solution to avoiding these penalties is to promote

collaboration between physicians and nurses during the delivery of

health care. However, promoting such collaboration can be chal-

lenging for hospitals. Indeed, these professions have distinct strict

regulations, which imply some separation between the two work-

forces. Furthermore, while both professions share a common goal,

i.e. caring for the patient, they have different knowledge bases (i.e.

different educations), which can lead to disagreements on the

approach to delivering care. This tension is exacerbated by the “cat

herding”problem, which is defined as the difficulty to retain and

direct individuals and which is common in PSF (Lorsch and Tierney,

2002). Thus, hospitals face the additional challenge of promoting

collaboration between nurses and physicians when each group it-

self presents management challenges. The purpose of this research

to investigate the following research question: How do hospitals

promote collaboration between physicians and nurses at the patient

level during the delivery of health care?

Weuse a casestudy approach to collect and analyzedata from the

heart failureunits of five major teaching hospitals(Hospitals A, B, C,

D&E) to investigate this question. Given our unit of analysis, we

henceforth refer to “Hospital X”when discussing the heart failure

unit of hospital X. Our case study involved 49 semi-structured in-

terviews regarding the delivery of care at both the strategic (e.g.

Chief Medical Officer, Chief Nursing Officer, Chief Quality Officer,

Director of Patient Experience) and operational levels (physicians

and nurses). We also supplemented this data with other forms of

data including training manuals, newsletters, scorecards, and orga-

nizational charts. The analyses revealed that physicians and nurses

experienced different challenges that prevented collaboration dur-

ing health care delivery. Specifically, physicians tended to focus on

the disease and operated based on technical standards. Asa result,

they tended to favor conformance quality, often at the expense of

experientialquality. We refer tothis preference as the disease-focus

challenge. Nurses were the primary interface with the patients and

were more familiar with important personal information such as

allergies, unique patients' circumstances, and their preferences,

which wasneeded to design effectivecare plans. However,we found

that nurses wereoften culturally challengedto speak up during care

delivery due to the hierarchical difference between nurses and

physicians.We refer to this cultural barrier as the hierarchical chal-

lenge. This also resulted in the unit's difficulty to promote collabo-

ration betweenphysicians and nurses.

Our analyses further revealed that the commonly prescribed

mechanisms, such as lateral collaboration between leaders of the

physician ei.e. medical eand nursing entities (Jansen et al., 2009)

and multi-disciplinary rounding involving nurses and physicians

(Gurses and Xiao, 2006), were present in all five hospitals but were

not sufficient to promote collaboration at the patient level during

health care delivery. What was interesting was that Hospital E,

which improved simultaneously on conformance and experiential

quality over the previous five years, had two different forms of

cross-level collaboration ephysician-led and nursing-led ewhich

are not discussed in the literature. Specifically, nursing-led cross-

level collaboration involves frequentinteractions between a higher

level of the nursing entity and a lower level of the physician entity.

It helped mitigate the disease-focus challenge experienced by

physicians. This form of cross-level collaboration was also present

in Hospital D. We also found that Hospital E had physician-led

cross-level collaboration, which involves frequent interactions be-

tween a higher level of the physician entity and a lower level of the

nursing entity. This collaboration helped mitigate the hierarchical

challenge faced by nurses. These results offer new insights into how

hospitals, and perhaps other PSF that rely on multiple professional

workforces, can encourage and support effective collaboration be-

tween professional entities.

2. Research design

2.1. Research sites

The research sites for this case study consist of the heart failure

units from five U.S. acute care hospitals. Our preliminary conver-

sations with the hospital leaders and caregivers suggested that

heart failure patients immensely benefit from high levels of

conformance and experiential quality. Indeed, the chronic aspect of

the heart failure condition makes it essential for caregivers to not

only properly diagnose and treat the symptoms of their disease in

the short-term but also to ensure that the patient understands and

agrees with the treatment plan and is able to adhere to it long after

discharge. Therefore, we selected the hospitals using secondary

data on conformance and experiential quality. Both the current

scores (see Table 1) and progression along conformance and

experiential quality (2006e2012; see Fig. 1) were used to sample

these hospitals. Following existing literature, we calculated

C. Senot et al. / Journal of Operations Management 42-43 (2016) 62e79 63