Intersection of Different Levels of Analysis: Macro, Meso, and Micro

In chapter 5, Jane Banaszak-Holl and Rosalind Keith demonstrate how culture change in nursing homes must be viewed at three levels: macro-, meso-, and microlevel phenomena intertwine concurrently to produce any sort of profound alteration of behavior to sustain genuine patient-centered care. Their application of the nursing home setting is critical to their argument and extremely valuable to consider for health care organization researchers and theorists. We are reminded that patients in nursing home facilities, unlike the majority of health care settings such as hospitals or physician clinics, are also residents of that facility. Though this may seem obvious, it is a critical distinction both sociologically and psychologically, creating a unique dynamic that is best captured in the combined examination of macro-, meso-, and microlevel phenomena, as Banaszak-Holl and Keith suggest. Timothy Hoff in chapter 7 states the need to make an explicit link between microprocesses in the workplace and macrolevel institutional, cultural, and policy forces. His strongly argued position is that organizational context must not be “controlled away” through standard research designs that attempt to isolate the impact of individual or multiple independent variables. Only in this manner can there be an explicit assessment of hypothesized links between contextual (i.e., environmental, market, and policy) forces and internal features of the organization that correspond to the microlevel nature of work, such as its emotional context, routines, motivation, engagement, and commitment, among others. Chapter 6, by Douglas Wholey, Xi Zhu, David Knoke, Pri Shah, and Katie White turns on true health care teamwork as deliberately and rationally connected to the health needs of specific populations and patients served. This is in essence an argument that microlevel team structures and processes should be designed according to the macrolevel presentation of diseases and population needs. Thomas D'Aunno's chapter 4 proposes a “middle ground” approach to understanding the necessary conditions that either favor or inhibit human agency and invokes the study of field-level, organizational-level, and individual-level factors that may be involved. In chapter 9, Mary Fennell, Steven Clauser, and Miriam Plavin-Masterman appeal to both macro- and microlevel analyses to understand how social network theory must be adapted to rise to the challenge of assessing the interaction of complex medical technologies contained in genomic medicine and new organizational forms for effective care delivery. And in the case for the application of SNA in health care presented in chapter 10, Timothy Huerta and Roberto Dandi tout SNA's ability to address social dynamics at multiple levels. These include focusing on individual actors, identifiable structures within networks (e.g., triads, cliques, or clans), and an entire network, representing the micro-, meso-, and macrolevels, respectively.

Standardization versus Improvisation and Adaptation

Timothy Hoff's discussion of routines with their life cycles, acceptance as a dominant logic, and ability to improve quality when multiple, complex steps are involved sets up a continuing dialogue in the chapters regarding times when deviation from routines may be required. In contrast, Mary Fennell and colleagues discuss in chapter 9 that health care has not yet developed an adequate or appropriate design for the effective provision of genomic-based care. This is because this form of care, highly individualized and to some extent unpredictable at the start, requires deviation from routines since standardized approaches will not match the needs of individual patients. Put another way, formal and informal routines can disrupt the fit between technology and structure in this domain of medicine. As a result, an individual physician's discretion will only be accentuated.

James Begun and Marcus Thygeson's vigorous defense of complexity science or complex adaptive systems in chapter 11 recognizes the value of improvisation by managers and researchers in solving recalcitrant and profound organizational problems. For them, it is important not to be captured and bound by traditional thinking, conventional routines, and historically grounded approaches to the complex issues confronting health care in the early twenty-first century.

What We Observe in Emerging Forms: Accountable Care Organizations and Primary Care Medical Homes

Almost every chapter makes some reference to either or both of the major organizational innovations that have been proffered as offering substantially improved ways of delivering health care: the primary care medical home (PCMH) and the accountable care organization (ACO). Apart from the high policy visibility that PCMHs and ACOs have had over the previous decade, it is not surprising that such a focus would exist in this book. Given that our authors are organizational analysts, any apparently new organizational form would attract special attention.

Banaszak-Holl and Keith mention PCMHs as an instance of an integrated team approach to primary care delivery. Huerta and Dandi point to a network structure that may respond well to the increasing demand for quality care and the heightened need for integration between primary and acute care providers, of which ACOs serve as a prime example. Shay and colleagues suggest that ACOs may be most effectively constructed through the more highly integrated, local and regional hospital-based systems that have now blanketed the nation.

But perhaps the most thorough discussion of an improved organization of care delivery is found in Wholey and colleagues' exhaustive approach to teams in health care. Although they do not argue that there is any one larger and overarching organizational form within which “real teams” may flourish, they do define “real teams” as those exhibiting clear membership boundaries, interdependence, and stable membership. These traits allow such entities to recognize and develop members' collective accountability for the team's outcomes. In this sense, the authors give a nod to ACOs as one promising context within which the prerequisites of care delivery teams may be implemented. The authors also repeatedly cite PCMHs as examples of care management teams that are favored for their ability to effectively meet service provision and care coordination needs.

Synthesizing Perspectives

Specific Synthetic Approaches

At first glance, it may appear that only chapters 6 and 10 address social network theory and that these chapters focus solely on considerations from the SNA perspective. However, a closer look yields evidence that the authors of these and other chapters integrate elements of alternative perspectives in their work.

In Douglas Wholey and colleagues' chapter, a foundational essay on the structures of teams, there is implicit invocation throughout their work of SNA. It is explicit at the end of their chapter. There is much discussion of the linkages among team members at the individual level and among organizational entities to address multiple needs of a given population. Discussion of who relates to whom and under what overall network structure is a major conceptual application by these scholars.

Interestingly, the idea of fit is at the base of the argument that care management teams will be “real teams” and that they will provide better and more comprehensive care when tailored to the actual health and social needs of a variety of patients and clients. The contingency here is the type of patient and what is appropriate care for the patient and the organizational form of care delivery. This is a classical structural contingency argument, and it follows Drazin and Van de Ven's (1985) systems approach to the analysis of congruence between structure and contingency's effect on performance. Thus, we see the combination of perspectives from social network theory and structural contingency theory, which is again revealed in chapter 10.

Huerta and Dandi's chapter on SNA makes an unequivocal statement that the exploration and study of networks is a fundamental starting point for understanding their behavior and performance. At the same time, however, these authors explicitly acknowledge the importance of other theoretical frames to provide a full understanding of network behavior. Similar to Wholey and colleagues, Huerta and Dandi connect SNA to structural contingency theory's concept of fit, explaining that network relationships are advantageous and allow members to increase their level of fitness and, as a result, their performance. As a construct, fit is also an important consideration of population ecology, and Huerta and Dandi speak to the population ecology perspective by acknowledging that network relationships provide the means for organizations to adapt to environmental demands, thereby ensuring their environmental fit and selection.

Beyond structural contingency theory and population ecology, Huerta and Dandi establish connections between social network theory and other organization theories. For example, in their explanations of how network relationships allow organizations to pursue strategic objectives, including efficiencies and access to resources, they elicit considerations of transaction cost economics and resource dependence theory. Institutional theory is invoked to help elaborate on the origin of tensions between professions as a function of conflicting values and perceptions (or competing logics). They argue that legitimacy is important to secure a network's long-term survival. Furthermore, network involvement may explain why some organizations mimic the behavior of others. And network centrality may allow physician opinion leaders to influence opinions, ideas, and behaviors of colleagues to whom they are linked. Such ties between social network theory and institutional theory, as portrayed by Huerta and Dandi, are also on display in chapter 4 by D'Aunno and chapter 5 by Banaszak-Holl and Keith.

Banaszak-Holl and Keith's chapter on culture and nursing homes uses an institutional theory argument regarding pressures favoring transformation or culture change. In addition, their study of culture change links both institutional theory and social network theory. They note that there are networks that may support nursing staff's adoption of resident-centered care. Simultaneously, the institutional forces represented in initiatives at both the state and federal levels have promoted culture change practices. Their chapter provides examples of how networks exert cultural-cognitive and normative pressures while regulatory bodies exert regulative pressure, all combined to promote culture change.

D'Aunno's chapter, which considers the issue of how institutional environments change, is also an exercise in synthetic thinking, notwithstanding its apparent focus on institutional theory. In his discussion of institutional entrepreneurs, he explains how these people leverage resources, including networks, to create new institutions or transform existing ones. Hence, there is a direct appeal to SNA, which appears numerous times in the chapter. An example is D'Aunno's demonstration of how stratified network positions can lead differentially to field-level contradictions and conflicts in expectations and performance; another is the different roles played by central versus peripheral network positions in motivating and enabling institutional change. Again, the author proposes how institutional change may occur as highly “embedded” persons take advantage of their intimate understanding of their organization's ability to create change. Other examples exist, and they reinforce Huerta and Dandi's general argument that SNA is a vital, if only recently appreciated, aspect of showing the causal pathways that involve the interaction of organizations, their environments, and both organizational and institutional change.

In addition to social network analysis, D'Aunno incorporates elements of other theoretical perspectives that complement the application of institutional theory. In order to address the problem of how institutional environments themselves may change, he focuses on the importance of competition for scarce resources as an impetus for change, a direct appeal to resource dependence theory. He also suggests that institutional change and entrepreneurship are more likely to occur in fields that are newer and less settled, consistent with the concept of inertia in population ecology that sees organizations as more and more resistant to change over time. Implicitly recognizing the complex nature of work practices, organizational relationships, and institutional logics, D'Aunno evokes principles from complexity theory in his statement that local improvisation and adaptation of organizational networks allow the reconciliation of differing logics. Furthermore, in discussing how organizations undergo change efforts to address negative performance stemming from institutional contradictions, his writing brings to mind the notion of SARFIT (structural adaptation to regain fit) in structural contingency theory, in which organizations adapt in response to failing performance so that they may regain their fit.

The interplay between structural contingency theory and institutional theory is particularly on display in chapter 9 by Fennell and colleagues. In reconciling the diffusion of disruptive technology and the reframing of institutional logics, they develop the foundation for a neostructural contingency theory. But even in the synthesis of structural contingency theory and institutional theory, we also see glimpses of social network theory and even population ecology. Fennell and colleagues affirm the connection between institutional theory and social network theory. They argue that institutional theorists view organizations as highly embedded in social structures, providing common meaning systems and fateful interactions. They also suggest a connection between structural contingency theory and social network theory: Fennell and colleagues view social relations and networks as an integral part of the organizational field, and the interpersonal connections and routines they produce may contribute to an organization's falling in and out of fit. And in a nod to the population ecology perspective, they describe the “liability of newness” that exists and complicates matters for organizations confronting disruptive technology and conflicting institutional logics. In the example they provide in chapter 9, organizations face considerable challenges when new technology is not ready to be coordinated effectively within multidisciplinary care delivery teams, and these teams' efforts at billing for new technology are hampered by the varied adoption and recognition of such technology across other organizations.

Hoff's chapter is a contemporary statement of the health care organization as a social work space. The metaphor permits a searching application of classical notions derived from decades of sociological thinking, deftly applied to modern questions about health care delivery. Among other devices he uses, Hoff argues that institutional frameworks intertwine with a classical “presentation of self in everyday life” formulation. Key to understanding this perspective is the idea of routines and their role in everyday health care. Without actually saying so, Hoff shows how SCT applies to the falling in and out of fit that occurs when routines work well and do not work well given changing contingencies in the organization. The difficulties of altering routines to meet changing contingencies is also an affirmation of the contention of population ecology that organizations are ill equipped to respond to changing environmental circumstances. Furthermore, routines are subject to institutional pressures, including the practices of other organizations, industry and regulatory standards, and beliefs maintained by the outside world. Hoff's arguments in chapter 7 are also consistent with the complex adaptive systems perspective, also known as complexity theory. Routines that work well can lead to improvement in overall quality, particularly in situations with multiple, complex steps. However, when unpredictable phenomena disrupt organizational life and work, the ability to adapt care to unique preferences, styles, abilities, and situations becomes very important.

Begun and Thygeson provide readers with an update on the state of complexity theory in chapter 11. As they present their case that complexity has an important place in health care organization practice and theory, their call to integrate complexity science into the toolbox of practitioners and researchers includes glimpses of how complexity is engaged in diverse theoretical perspectives. They explicitly connect complexity science to SNA, describing complex systems as driven by social structures that dictate system processes and behaviors. On the other side of the coin, Begun and Thygeson recognize that relationships themselves are complex, even to the extent they exhibit fractal characteristics. Furthermore, complexity theory views health care organizations as complex adaptive systems, meaning they are resilient, composed of heterogeneous agents, and responsive to feedback. This view that organizations are able to adapt to a changing environment is consistent with the SCT perspective, particularly the notion that organizations strategically adapt in response to environmental changes so that they may achieve fit. It also contrasts with the population ecology perspective, which sees organizations as experiencing great difficulty when confronted with the need to adapt to meet environmental demands. In their discussion of methods and tools to analyze complex adaptive systems, Begun and Thygeson promote an approach that understands organizations as “holistic entities comprising interconnected and interacting elements” that include organizational structure, strategy, culture, and the environment. Together these elements influence organizational performance, and the authors argue that such a perspective is needed to evaluate complex health care delivery forms such as integrated health care systems, PCMHs, and ACOs.

Shay and colleagues present in chapter 8 a multitheoretical perspective to explain hospital-based clusters that includes theories accounting for elements such as structure (such as structural contingency theory and transaction cost economics), strategy (such as resource dependence theory), culture (such as institutional theory), and the environment (such as population ecology). The authors make an explicit attempt to integrate multiple organization theories into a single model, as they believe that each of the different perspectives speaks to the complex arrangements of clusters and contributes to our understanding of their varied forms. In many ways, this book's chapters and their depictions of how various organization theories are connected confirm Shay and colleagues' argument that researchers must strive to develop and apply multitheoretical perspectives.