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 into the complementary between top-down and bottom-up decision processes in hospitals.