Patient-physician relationships are an important factor in patients taking a more active role in their health and health care. Efforts to increase activation that focus only on individual patients ignore the important fact that the nature of roles and relationships between provider and patient can shape the behaviors and attitudes of patients in ways that support or discourage patient activation.

Interest in organizational contributions to the delivery of care has risen significantly in recent years. A challenge facing researchers, practitioners, and policy makers is identifying ways to improve care by improving the organizations that provide this care, given the complexity of health care organizations and the role organizations play in influencing systems of care. This article reviews the literature on the relationship between the structural characteristics and organizational processes of hospitals and quality of care. The review uses Donabedian's structure-process-outcome and level of analysis frameworks to organize the literature. The results of this review indicate that a preponderance of studies are conducted at the hospital level of analysis and are predominantly focused on the organizational structure-quality outcome relationship. The article concludes with recommendations of how health services researchers can expand their research to enhance one's understanding of the relationship between organizational characteristics and quality of care.

BackgroundMany delivery-system interventions are fundamentally about change in social systems (both planned and unplanned). This systems perspective raises a number of methodological challenges for studying the effects of delivery-system change--particularly for answering questions related to whether the change will work under different conditions and how the change is integrated (or not) into the operating context of the delivery system.MethodsThe purpose of this paper is to describe the methodological and measurement challenges posed by five key issues in delivery-system research: (1) modeling intervention context; (2) measuring readiness for change; (3) assessing intervention fidelity and sustainability; (4) assessing complex, multicomponent interventions; and (5) incorporating time in delivery-system models to discuss recommendations for addressing these issues. For each issue, we provide recommendations for how research may be designed and implemented to overcome these challenges.Results and conclusionsWe suggest that a more refined understanding of the mechanisms underlying delivery-system interventions (treatment theory) and the ways in which outcomes for different classes of individuals change over time are fundamental starting points for capturing the heterogeneity in samples of individuals exposed to delivery-system interventions. To support the research recommendations outlined in this paper and to advance understanding of the "why" and "how" questions of delivery-system change and their effects, funding agencies should consider supporting studies with larger organizational sample sizes; longer duration; and nontraditional, mixed-methods designs.A version of this paper was prepared under contract with the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services for presentation and discussion at a meeting on "The Challenge and Promise of Delivery System Research," held in Sterling, VA, on February 16-17, 2011. The opinions in the paper are those of the author and do not represent the views or recommendations of AHRQ or the US Department of Health and Human Services.1

The review revealed several important gaps in the QI implementation literature. Studies often lacked clear conceptual frameworks to guide the research, which may hinder efforts to compare relationships across studies. Studies also tended to adopt designs that were narrowly focused on independent effects of predictors and did not include holistic frameworks to capture interactions among the many factors involved in implementation. Other design limitations included the use of cross-sectional designs, single-source data collection, and potential selection bias among study participants.

Capacity building is often described as fundamental to the success of health alliances, yet there are few evaluations that provide alliances with clear guidance on the challenges related to capacity building. This article attempts to identify potential challenges of capacity building in multistakeholder health alliances. The study uses a multiple case study design to identify potential challenges and trade-offs associated with capacity building in four community health alliances in the United States. Multiple challenges were found to be common across the four alliances, including specifying appropriate governance structures and decision-making frameworks, aligning stakeholder interests with the vision of the alliance, balancing short-term objectives with long-term goals, and securing resources to sustain the effort without compromising it. These challenges often involved trade-offs and choices that alliances need to prepare for if they are to approach capacity building in a planful rather than a reactive manner.