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This dissertation aims at understanding the organizational antecedents and performance consequences for hospitals of combining conformance quality and experiential quality when delivering care. Conformance quality reduces variance around a set of technical guidelines and has been a long standing priority in health care delivery. Experiential quality requires a shift in culture and focuses on the quality of interactions between caregivers and patients and by definition enhances variance. In the context of health care delivery, reconciling both quality dimensions has proven a challenge given the need for the same caregiver to simultaneously focus on two dimensions that trigger different learning mechanisms. Existing theories on reconciling dual learning goals are not adapted to the particularities of this setting. This dissertation develops a framework on combining conformance and experiential quality in the health care delivery context through three inter-related studies that use multiple methods.The first study, “The Impact of Combining Conformance and Experiential Quality on Health Care Clinical and Cost Performance”, investigates whether overcoming the tensions between conformance quality and experiential quality has an impact on the effectiveness of care delivery. The study builds on the quality management and organizational learning literature to investigate the impact of combining experiential and conformance quality dimensions on clinical and cost outcomes. Hypotheses are tested using secondary data from 9 distinct sources on 3474 U.S. acute care hospitals over a six-year period. Econometric analyses indicate that combining conformance and experiential quality promotes clinical outcomes but at the expense of cost efficiency. The second study, “The Effects of Coordination Mechanisms on Combining Conformance and Experiential Quality in the Delivery of Care: A Multi-Method Study”, investigates the effect of top-down control versus bottom-up decision-making mechanisms on hospitals’ ability to simultaneously improve on conformance and experiential quality. This study adopts a theory building approach, iterating between extant organizational learning and operations management literature and a multiple-case study involving 49 semi-structured interviews of heart failure units across 5 U.S. acute care hospitals. Hypotheses are then tested using secondary data for a sample of 2031 U.S. acute care hospitals. Results reveal that bottom-up decision-making increases the likelihood for hospitals to simultaneously improve on both process quality dimensions but this effect only partially mutes the direct negative effect of top-down control. This indicates the need to look for further organizational mechanisms that allow hospitals to combine conformance and experiential quality when delivering care.The third study, “Pursuing Conformance Quality and Experiential Quality during the Delivery of Health Care: Evidence from a Multiple-Case Study in U.S. Hospitals”, is a multiple-case study conducted in the heart failure units of 5 major teaching hospitals. It involves 49 semi-structured interviews with caregivers and administrators, complemented by the collection of additional material as well as participation to multiple training sessions. Through a grounded theory building approach, this study offers a deeper understanding on the organizational mechanisms that allow successful combination of conformance and experiential quality. Qualitative analyses reveal that cross-level collaboration between medical and nursing functional entities is an important antecedent for hospitals to overcome the tensions between conformance and experiential quality. |
