Objective: To understand fundamental attitudes towards patient safety culture and ways in which attitudes vary by hospital, job class, and clinical status.

Design: Using a closed ended survey, respondents were questioned on 16 topics important to a culture of safety in health care or other industries plus demographic information. The survey was conducted by US mail (with an option to respond by Internet) over a 6 month period from April 2001 in three mailings.

Setting: 15 hospitals participating in the California Patient Safety Consortium.

Subjects: A sample of 6312 employees generally comprising all the hospital’s attending physicians, all the senior executives (defined as department head or above), and a 10% random sample of all other hospital personnel. The response rate was 47.4% overall, 62% excluding physicians. Where appropriate, responses were weighted to allow an accurate comparison between participating hospitals and job types and to correct for non-response.

Main outcome measures: Frequency of responses suggesting an absence of safety culture ("problematic responses" to survey questions) and the frequency of "neutral" responses which might also imply a lack of safety culture. Responses to each question overall were recorded according to hospital, job class, and clinician status.

Results: The mean overall problematic response was 18% and a further 18% of respondents gave neutral responses. Problematic responses varied widely between participating institutions. Clinicians, especially nurses, gave more problematic responses than non-clinicians, and front line workers gave more than senior managers.

Conclusion: Safety culture may not be as strong as is desirable of a high reliability organization. The culture differed significantly, not only between hospitals, but also by clinical status and job class within individual institutions. The results provide the most complete available information on the attitudes and experiences of workers about safety culture in hospitals and ways in which perceptions of safety culture differ among hospitals and between types of personnel. Further research is needed to confirm these results and to determine how senior managers can successfully transmit their commitment to safety to the clinical workplace.

Objective: Most infections occur during childhood, but the health effects of childhood infection are poorly understood. We investigated whether growth decreases in the 2 months after acute seroconversion.

Methods: We performed a nested case-control study among children 6 months to 12 years of age in a community on the outskirts of Lima, Peru. Health interviews were completed daily. Anthropometric measurements were taken monthly. Sera were collected every 4 months and tested for immunoglobulin G. Two-month height and weight gains of seroconverters were compared with gains of sex, age, and size-matched seronegative controls.

Results: In the 2 months after infection, 26 seroconverters gained a median of 24% less weight than 26 matched controls (interquartile range, 63% less to 21% more). In multivariate analysis, infection attenuated weight gain only among children aged 2 years or older. This decrease was not explained by increased diarrhea.

Conclusions: Seroconversion is associated with a slowing of weight gain in children aged 2 years or older. Reasons for this finding merit additional study.

Although the fields of organization theory and social movement theory have long been viewed as belonging to different worlds, recent events have intervened, reminding us that organizations are becoming more movement-like - more volatile and politicized - while movements are more likely to borrow strategies from organizations. Organization theory and social movement theory are two of the most vibrant areas within the social sciences. This collection of original essays and studies both calls for a closer connection between these fields and demonstrates the value of this interchange. Three introductory, programmatic essays by leading scholars in the two fields are followed by eight empirical studies that directly illustrate the benefits of this type of cross-pollination. The studies variously examine the processes by which movements become organized and the role of movement processes within and among organizations. The topics covered range from globalization and transnational social movement organizations to community recycling programs.

Objectives. Concerns have mounted about the complexities of the health care system potentially causing significant unintended adverse effects. With a major national interest in addressing patient safety issues, a wide spectrum of individuals and organizations are working toward developing methods and systems to detect, characterize, and report potentially preventable adverse events. One approach is to develop screening measures based on routinely collected administrative data, such as the patient safety indicators (PSIs) reported here. The purpose of the PSI project is to report 1) literature-based evidence on potential PSIs, 2) clinician panel review results of potential indicators, 3) empirical analyses on a subset of indicators, and 4) recommendations regarding potential PSIs.

Methods. A four-pronged strategy to collect validation data and descriptive information was used: 1) background literature review, 2) structured clinical panel reviews of candidate PSIs, 3) expert review of ICD-9-CM codes in candidate PSIs, and 4) empirical analyses of the potential candidate PSIs. Evidence from these four sources was used to modify and select the most promising indicators for use as a screening tool to provide an accessible and low-cost approach to identifying potential problems in the quality of care related to patient safety.

Main results. A review of previously reported measures in the literature, and of medical coding manuals, resulted in identification of over 200 ICD-9-CM codes representing potential patient safety problems. Most of these codes were grouped into clinically meaningful indicators either based on previous indicator definitions or on clinical and coding expertise. Based on literature review of the published evidence related to their validity, several potential PSIs were eliminated. Because of the limited validation literature available on PSIs and complications indicators from which many PSIs were derived, the research team conducted a clinical panel review process to assess the face validity and to guide refinements to the initial definitions of the 34 most promising PSIs. Response to a questionnaire by clinicians (i.e., physicians from a number of specialties, nurses, and pharmacists) for each indicator, augmented by coding review and initial empirical testing, provided the basis for selecting the indicators expected to be most useful for screening for potentially preventable adverse events. Twenty hospital level PSIs are recommended for implementation as the initial AHRQ PSI set (designated Accepted indicators).

Conclusions and future research. Future validation work should focus on the sensitivity and specificity of these indicators in detecting the occurrence of a complication; the extent to which failures in processes of care at the system or individual level are detected using these indicators; the relationship of these indicators with other measures of quality, such as mortality; and further explorations of bias and risk adjustment. Enhancements to administrative data are worth exploring in the context of further validation studies that utilize data from other sources. The current development and evaluation effort will best be augmented by a continuous communication loop between users of these measures, researchers interested in improving these measures, and policy makers with influence over the resources aimed at data collection and patient safety measurement.

A best seller in its first edition, Institutions and Organizations has been thoroughly revised and expanded. This second edition provides a comprehensive overview of the institutionalist approach to organization theory. Dick Scott presents a historical overview of the theoretical literature, an integrative analysis of current institutional approaches, and a review of empirical research related to institutions and organizations. He offers an extensive review and critique of institutional analysis in sociology, political science, and economics as it relates to recent theory and research on organizations.

The second edition gives particular attention to the topics of agency and structure and to institutional change. Given the constraining and constitutive properties of institutions, how can actors intervene to introduce novelty? How is change possible? To a previous concern with "convergent" change, a focus on increasing structural isomorphism, the author adds a thorough analysis of the sources of "disruptive" change, deinstitutionalization, and the emergence of new kinds of institutions.

First edition 1995; Selected as one of the Outstanding Academic Books of 1995 by Choice.

Healthcare quality has received heightened attention over the last decade, leading to a growing demand by providers, payers, policymakers, and patients for information on quality of care to help guide their decisions and efforts to improve health care delivery. At the same time, progress in electronic data collection and storage has enhanced opportunities to provide data related to health care quality. In 1989, the Agency for Health Care Policy and Research (AHCPR, now the Agency for Healthcare Research and Quality, AHRQ) initiated the Healthcare Cost and Utilization Project (HCUP). HCUP is an ongoing federal-state-private collaboration to build uniform databases from administrative hospital-based data collected by state data organizations and hospital associations.

The HCUP quality indicator set, developed in 1994, and hereafter referred to as HCUP I, consists of 33 measures, constructed using administrative data available in the NIS. Included in the set are indicators of utilization of procedures, ambulatory care sensitive condition admissions, post-operative and other complications, and mortality.

Since the original HCUP QI development work in 1994, numerous managed care organizations, state Medicaid agencies and hospital associations, quality improvement organizations, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), the National Committee on Quality Assurance (NCQA), academic researchers and others have contributed substantially to the knowledge base of hospital quality indicators. Based on input from current users and advances to the scientific base for specific indicators, AHRQ decided to fund a research project to refine and further develop the HCUP QIs.

As a result, AHRQ charged the UCSF-Stanford Evidence-based Practice Center (EPC) to revisit the initial 33 indicator set (HCUP I QIs), evaluate their effectiveness as indicators, identify potential new indicators, and ultimately propose a revised set of indicators. This report documents the evidence project to develop recommendations for improvements to the HCUP I indicators.

With the backlash against managed care, medical necessity has become the focus of increasing controversy. California's health care marketplace has provided some unique opportunities to understand the role of medical necessity in managed care decisionmaking, as the legislature and stakeholders have discovered how little consensus there is on itsmeaning, ownership, and application. Nevertheless , many decisionmakers agree that medical necessity decisions generally involve authorizing treatment for an individual patient. These differ from coverage decisions, which set organizational policies regarding the coverage of treatments for populations of patients with similar conditions. Both types of decisions require medical judgment, and thus both mix considerations of payment and clinical factors.3 Differences in coverage policies and in the application of those policies to individual decisions contribute to variation in managed care decision making.

Previous research has found considerable variation in the process and criteria used for decision making in both public and private plans. The aim of our research was to understand more precisely what type of variation exists and whether more clarity and consistency in medical necessity decision making could make a difference to consumers and providers. We sought to document differences in decision-making criteria and to explain the relationship between contractual definitions and the way decisions are made in practice. Given the lack of existing information on how medical necessity decisions are made in managed care organizations, we believed that describing "best practices" as well as unacceptable variations could play a powerful role, along with consumer choice and regulatory fiat, in improving the process. Finally, we sought to produce, with stakeholders' involvement, a model contractual definition and decision-making process based on best-practices models.

Few large institutions have changed as fully and dramatically as the U.S. healthcare system since World War II. Compared to the 1930s, healthcare now incorporates a variety of new technologies, service-delivery arrangements, financing mechanisms, and underlying sets of organizing principles.

This book examines the transformations that have occurred in medical care systems in the San Francisco Bay area since 1945. The authors describe these changes in detail and relate them to both the sociodemographic trends in the Bay Area and to shifts in regulatory systems and policy environments at local, state, and national levels. But this is more than a social history; the authors employ a variety of theoretical perspectives - including strategic management, population ecology, and institutional theory - to examine five types of healthcare organizations through quantitative data analysis and illustrative case studies.

Providing a thorough account of changes for one of the nation's leading metropolitan areas in health service innovation, this book is a landmark in the theory of organizations and in the history of healthcare systems.

This book received the Max Weber Award from the American Sociological Association, Section on Organizations, Occupations and Work for best scholarly book in 2001

The 35 chapters of The Handbook of Health Economics provide an up-to-date survey of the burgeoning literature in health economics. As a relatively recent subdiscipline of economics, health economics has been remarkably successful. It has made or stimulated numerous contributions to various areas of the main discipline: the theory of human capital; the economics of insurance; principal-agent theory; asymmetric information; econometrics; the theory of incomplete markets; and the foundations of welfare economics, among others. Perhaps it has had an even greater effect outside the field of economics, introducing terms such as opportunity cost, elasticity, the margin, and the production function into medical parlance. Indeed, health economists are likely to be as heavily cited in the clinical as in the economics literature. Partly because of the large share of public resources that health care commands in almost every developed country, health policy is often a contentious and visible issue; elections have sometimes turned on issues of health policy. Showing the versatility of economic theory, health economics and health economists have usually been part of policy debates, despite the vast differences in medical care institutions across countries. The publication of the first Handbook of Health Economics marks another step in the evolution of health economics.