Role of Bottom-Up Decision Processes in Improving the Quality of Health Care Delivery : A Contingency Perspective

Recent changes to health care reimbursements policy mandate hospitals to improve simultaneously on conformance and experiential quality. Conformance quality measures the level of caregivers’ adherence to evidence-based standards of care while experiential quality measures the level of interaction between caregivers and patients. Hospitals operate in regulated environments characterized by heavy top-down control mechanisms that are conducible for improving conformance quality. However, mechanisms that propel experiential quality, which emerges from the operational-level interactions between caregivers and patients, remain unclear. This study employs a two-phase multi-method research to investigate this issue. The first phase uses qualitative data from five U.S. acute care hospitals involving 49 semi-structured interviews and develops hypotheses on the effect of bottom-up and top-down decision processes on hospitals’ ability to simultaneously improve on conformance and experiential quality. These hypotheses are then tested and refined using secondary data for a sample of 3,124 U.S. acute care hospitals between the years of 2006 and 2012. Results from the case analyses suggest that Magnet status, a sign of bottom-up decision processes, is associated with hospitals’ ability to improve on both conformance and experiential quality. However, hospitals’ administrative intensity, which relates to top-down decision processes, appears to mitigate the effect of Magnet status on simultaneous improvement. Testing this framework using large scale secondary data supports the positive effect of Magnet status on simultaneous improvement. However, we do not find support for a negative moderating effect of administrative intensity. A follow-up analysis reveals that this moderation is in fact curvilinear (inverted U-shape), which indicates that a moderate level of administrative intensity is most beneficial to the relationship between Magnet status and simultaneous improvement. Taken together, our results provide new insights on the complementary between top-down and bottom-up decision processes in hospitals