How institutional change and individual researchers helped advance clinical guidelines in American health care

Abstract

Clinical guidelines are important tools for managing health care quality. Research on the origins of guidelines primarily focuses on the institutional causes of their emergence and growth. Individual medical researchers, however, have played important roles. This paper develops knowledge of the role of individual medical researchers in advancing guidelines, and of how researchers' efforts were enabled or constrained by broader institutional changes. Drawing on an analytical case study focused on the role of Kerr White, John Wennberg, and Robert Brook, it shows that guidelines were a product of the interplay between institutional change in the medical field and actions by individual researchers, acting as institutional entrepreneurs. Increased government involvement in the health care field triggered the involvement of a range of new actors in health care. These new organizations created a context that allowed individual researchers to advance guidelines by creating job opportunities, providing research funding, and creating opportunities for researchers to engage with the policy process. Individual researchers availed of this context to both advance their ideas, and to draw new actors into the field.

Career Resourcing and the Process of Professional Emergence

“…HSR emerged and was institutionalized as a profession between the 1930s and the 1990s. It was created during a period of dramatic expansion of the American healthcare system and growing involvement of the federal government in it (Dunn & Jones, 2010;Nigam, 2013;Scott, Ruef, Mendel, & Caronna, 2000;Starr, 1982;Stevens, 2000).…”

“…quality assurance), 4 secondary and commissioned histories of organizations that supported HSR, and other secondary research that touches on the history of HSR and the evolution of the American health care system more broadly post World War II (e.g. Dunn & Jones, 2010;Nigam, 2012aNigam, , 2013Scott et al, 2000;Starr, 1982;Stevens, 2000;Timmermans & Berg, 2003;Wiener, 2000).…”

Chapter 8 Mentoring Institutional Change: Intergenerational Construction of Meso-structure and the Emergence of New Logics in American Healthcare

“…Historical case studies are suitable for studying change processes that unfurl over extended periods of time where actions by diverse people can accumulate in a way that shapes some outcome, such as the emergence of a new institutional logic (Kieser, 1994;Yin, 2003). This case study was part of a larger project focused on the origins and effects of evidence-based medicine, and the emergence of health services research (Nigam, 2012(Nigam, , 2013. We draw primarily on a set of 20 oral history interviews with 19 key people involved in the emergence of evidence-based medicine.…”

“…We selected these interviews because of prior research suggesting that prominent early founders of health services research, including Wennberg, played a key role in establishing the intellectual foundation for evidence-based medicine. Complementing the oral histories, we also draw on primary documents such as papers published by key players in the evidence-based medicine intellectual school, secondary histories of evidence-based medicine, and Institute of Medicine reports relating to evidence-based medicine (For additional description of our historical case study methods see Nigam, 2012Nigam, , 2013.…”

“…Both are specific forms of professionalism (Freidson, 1984). Table 1 describes the two institutional logics, drawing on prior research about the emergence of evidence-based medicine (Lambert, Gordon, & Bogdan-Lovis, 2006;Nigam, 2012Nigam, , 2013Timmermans & Berg, 2003). The logic of individual professionalism was consistent with the larger system of professional dominance that prevailed in the U.S. healthcare system since the beginning of the 20 th century (Freidson, 1970;Light, 1992;Scott, Ruef, Mendel, & Caronna, 2000).…”