Market Research and Management: Health care setting in an organization

As pilot study for the main research, on an organisation / sector /product / service of your choice analyse qualitative and quantitative primary research data.  On the basis of this analysis provide the organisation with recommendations for the main research with defined research objectives. (2000 words)Executive summary

The authors conducted a pilot test of the organizational culture model in a health care setting. The study was based on a questionnaire with mixed quantitative and qualitative analysis. Quantitative analysis confined the expected distribution of responses among the subcultures for all three questions, with significant differences in woof the three. Qualitative analysis further strengthened these results. The authors believe the organizational culture model may be a useful tool for making sub-cultural differences explicit, showing opportunities for better information exchange and opening dialogue between groups. These data should be confirmed with larger studies using psychometrically sound outcome instruments.

Introduction

An academic medical clinic is a complex organization. It is also a system made up of diverse groups of individuals with specific language, artifacts, rules, and divisions of labor interacting to achieve a common purpose. These parts of a system operate interdependently so that small changes in one part can cause large changes for the whole system.One of the fundamental characteristics of a system is its culture. a pattern of basic assumptions—invented, discovered or developed by a given group as it learns to cope with its problems of external adaptation or internal integration—that has worked well enough to be considered valid, and therefore, to be taught to new members as the correct way to perceive, think and feel in relation to those problems. Organizational culture also has been described simply as “the way we do things around here.”-‘!”-“‘ An understanding of organizational culture has been validated for use as a model to predict and manage changes within manufacturing organizations.” While the model has not been validated in a medical setting, we believe this construct also may provide useful insights into the behavior of health care organizations as they face conflicting pressures and respond with rapid change. This article reports on an exploratory study to assess the value of the organizational culture model in the academic medical clinic of a Veterans Affairs (VA) Medical Center. We hypothesized that organizational subcultures existed at the medical center and that tensions between and among these subcultures were responsible for some of the conflict seen as the center converted to a capitated model.

A pilot study is a preliminary trial of research which is essential to the development of an extensive training program. In a pilot study the entire training program is carried out but with fewer participants that would be used for an extensive training program. In addition to achieving all the objectives of the usual tryout, such as improving data collecting routines, and checking the appropriateness of standard measures, the pilot study provides additional knowledge that leads to  an improved training program. The pilot study greatly reduces the number of treatment errors because unforeseen problems revealed in the study may be overcome in redesigning the workbooks or the training program itself.Body

Schein takes the view that culture develops on the basis of shared experience and common history of a definable, stable group. Therefore, Schein theorizes that within a given organizational culture, there exist several subcultures. A change in any one of these subcultures can threaten the stability of any of the other subcultures, which then organize to defend themselves against the effects of change. Schein states that there are three subcultures in any organization that are particularly important to understand the dynamics of change,”*’^ these three cultures are

1. Operator culture—This consists of the people on the front line who deliver the products or services promised by the organization. Applying Schein’s concepts to the academic medical center, this group consists of clinic staff, nurses, trainees, and faculty; their focus is on health maintenance and illness prevention in their patient population. The operator culture relies on high levels of communication, trust, and teamwork to get things done. This culture’s daily experience is that no matter how well specified rules and procedures might be, there always will be unpredictable contingencies and surprise. They recognize that individual people make the difference and are the organization’s ultimate asset.2. Engineer culture —This group designs the processes by which the organization delivers its products and services and by which it maintains itself. The engineers share a common worldview based on education, shared technology, and work experience. They rely on technological elegance to achieve reliable and efficient operations. Applying these concepts to a medical clinic, the engineer culture includes information systems managers, clinical guideline developers, and some subspecialists (to the extent that they apply algorithmic approaches rather than individual approaches). While the operator culture recognizes its interdependence with others in their group, the engineer culture views itself on a global basis, identifying with its professional groups outside the institution rather than with colleagues within the organization.

3. Executive culture —Executives are responsible for the strategic survival of their organization and concern themselves with decreasing costs and maximizing profits. The executives believe that hierarchy is intrinsic to organizational control and coordination and they generally are far removed from front-line operations. Their world is composed of imperfect information that they must act on, often trading long-term goals (e.g., adaptability, innovation, or cohesiveness) for short-term coping strategies (e.g., increased market share, decreased costs). They may feel isolated, alone, and responsible. Like the engineers, the executives often identify with their counterparts outside the organization rather than their colleagues within the organization.

METHODS

Questionnaire development and subculture predictionsOur hospital was under pressure to add new patients because the VA system was switching to capitated reimbursement. Schein’s organizational culture model seemed to explain several difficulties we were experiencing during this change. We hypothesized that the executive, engineer, and operator cultures existed within our organization and that their views about the capitated model would be aligned within their own subculture but would be at odds with the other two groups.

To demonstrate this, we developed three test questions that positioned one subculture’s assumptions against another’s. These three test questions were inserted into a larger clinic questionnaire. Each question had a five-point scale with anchors for each point appropriate to that question (e.g., from “strongly agree” to “strongly disagree” or from “should be much more” to “should be much less”). Respondents were asked to circle a descriptor and support their beliefs with a brief written statement. We expected that members from one culture would be polarized toward one end; members from the competing culture would be polarized toward the other end. And members from the third culture would be less homogeneous and grouped near the middle because the question did not address any of their critical variables.

To validate the questionnaire, we conducted a pilot test in a focus group of personnel that were excluded from the final testing sample. The focus group (n = 6) included members of all subcultures and the results supported the existence of the organizational culture model. Following discussion with the same focus group, the questionnaire was revised to decrease ambiguity. In the final version, question one stated, “Increasing workload is negatively affecting quality and satisfaction,” question two stated “Guidelines and models are practical to use for daily activities in clinic.” and question three stated “The Boise VAMC devotes just the right amount of resources to support guidelines and models.” The questionnaire was distributed to the entire clinic staff, residents, faculty, and administration (n = 60) with an overall response rate of 65 percent. Before analyzing the questionnaire, the authors (with more than 40 years of combined experience at the medical center) predicted into which culture each respondent would best fit based on job description and familiarity with the individual’s role in the institution. There was near perfect inter rater agreement about these assignments. The executive culture (n = 6) included the hospital director, administrative assistant to the director, chief of staff, staff assistant to the chief of staff, associate chief of staff for administrative medicine, and executive secretary to the chief of staff. The engineer culture {n = 5) included a physician who headed a team for creation of clinical guidelines, a nurse and a nurse practitioner who were involved in creation of the interdisciplinary firm system, and a physician and physician assistant involved in a computer-generated preventive medicine reminder project for the clinic.

While one author also would fall in this group, all authors were excluded from the analysis. All others {n = 49) had frequent patient care duties, no significant duties involving prediction and control, and were considered to be part of the operator culture.

RESULTS AND ANALYSISQuantitative analysis

Overall response rate was 65 percent. The response rate was 67 percent (4/6) for the executive culture, 100 percent (5/5) for the engineer culture, and 61 percent (30/49) for the operator culture. A few executives at the highest levels did not respond, leading to a possible source of error. The average score for all respondents on all questions was 3, 4 (1-5 possible) with a standard deviation of 0.92. This suggests a low likelihood of a ceiling or floor effect on the questionnaire and shows, as hypothesized, a wide variability in responses. Question .scores by predicted group was computed using analysis of variance.

Executive versus operator

As mentioned above, the statement, “Increasing workload is negatively affecting quality and satisfaction,” was designed to separate the executive and operator cultures, pitting desire to increase market share against time pressures and perception of quality. Figure 1 shows the results of quantitative analysis of this question.

Engineer versus operator

The statement “Guidelines and models are practical to use for daily activities in clinic” was designed to separate the engineer and operator cultures, pitting control measures against pragmatic usefulness. Figure 2 shows the results of quantitative analysis of this question.

Executive versus engineer

The statement “The Boise VAMC devotes just the right amount of resources to support guidelines and models” was designed to separate the engineer and operator cultures, pitting incremental cost against increased precision. Figure 3 shows the results of quantitative analysis of this question.

Qualitative analysts

Respondents provided brief statements in support of their beliefs in 42 percent of the responses. There was no difference among groups in willingness to offer qualitative responses. Statements were analyzed blindly by recursively grouping them into conceptual bins using Non-numerical, Unstructured Data – Indexing, Structuring and Theorizing. The data then were analyzed within the new coding system until new discrepancies were found and negotiated. This iterative process continued (six iterations) until the following stable set of coding concepts was created: cost; market share; efficiency; variability; guideline; poor quality; good quality; capacity; increased resources; time pressure; stress; and not work (meaning the concept didn’t or wouldn’t work). Coding with this stable set of concepts showed a final inter-rater agreement of 85 percent, which was consistent across subcultures.

Executive versus operator

The following are selected qualitative statements made in response to the question “Increasing workload is negatively affecting quality and satisfaction.” These statements, which are representative of each group, are followed by the corresponding statement that was circled on the questionnaire (used for quantitative analysis) and the qualitative coding concept assigned to that statement, both in parentheses.

Engineer versus operatorThe following are selected qualitative statements made in response to the question “Guidelines and models are practical to use for daily activities in clinic,” These statements, again chosen to be representative of each group, also are followed by the corresponding statement that was circled on the questionnaire (used for quantitative analysis) and the qualitative coding concept assigned to that statement, both in parentheses.

Engineer versus executive

The following are selected qualitative statements made in response to the question “The Boise VAMC devotes just the right amount of resources to support guidelines and models.” These statements, again chosen to be representative of each group also are followed by the corresponding statement that was circled on the questionnaire (used for quantitative analysis) and the qualitative coding concept assigned to that statement, both in parentheses.

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