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2015
Toward Transforming Health Systems: A Practice
Study of Organizing and Practical Inquiry in
Academic Medicine
Tomas A. Ellison
Antioch University - PhD Program in Leadership and Change
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Recommended Citation
Ellison, Tomas A., "Toward Transforming Health Systems: A Practice Study of Organizing and Practical Inquiry in Academic
Medicine" (2015). Dissertations & Teses. 248.
htp://aura.antioch.edu/etds/248
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TOWARD TRANSFORMING HEALTH SYSTEMS:
A PRACTICE STUDY OF ORGANIZING AND PRACTICAL INQUIRY
IN ACADEMIC MEDICINE
THOMAS A. ELLISON
A DISSERTATION
Submitted to the Ph.D. in Leadership and Change Program
of Antioch University
in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
July, 2015
This is to certify that the Dissertation entitled:
TOWARD TRANSFORMING HEALTH SYSTEMS: A PRACTICE STUDY OF
ORGANIZING AND PRACTICAL INQUIRY IN ACADEMIC MEDICINE
prepared by
Thomas A. Ellison
is approved in partial fulfillment of the requirements for the degree of Doctor of
Philosophy in Leadership and Change.
Approved by:
___________________________________________________________________________
Alan E. Guskin, Ph.D., Chair date
___________________________________________________________________________
Laura Morgan Roberts, Ph.D., Committee Member date
___________________________________________________________________________
Jon F. Wergin, Ph.D., Committee Member date
___________________________________________________________________________
William M. Plater, Ph.D., External Reader date
Copyright 2015 Thomas A. Ellison
All rights reserved
Acknowledgements
I have received seemingly unlimited inspiration and support in my journey to explore my
new professional pathway and new pathways for research and learning about the organizational
side of professional life. The inspiration started with my work as a trustee at Westminster
College, where many have been mobilized by the vision of former President Michael Bassis to
change the work of faculty from merely teaching to delivering documented student learning
outcomes. Michael introduced me to his lifelong mentor, Al Guskin, and his work to the address
unsustainable cost model in higher education and develop a new student learning model for a
Ph.D. in Leadership and Change. The very topics of this Program as well as its learning design
were inspirational to me. In addition to being a patient and practical chair of my dissertation
committee, Al Guskin has provided important advice and encouragement for matters both inside
and outside of the Program for which I am very grateful. My other committee members Jon
Wergin and Laura Morgan Roberts have had significant impacts on my learning throughout my
time in the Program and also in shaping this dissertation, for which I am also grateful. I also
have appreciated the diligence and contributions of William Plater as an external reader of this
dissertation.
I owe a debt of gratitude to Joseph Rouse, of Wesleyan University, who served as a
mentor for an earlier project on practice theories. Professor Rouse patiently guided me in my
learning of philosophy and studies of science, a challenging task because I had no background in
philosophy or science. But his commitment to cultural studies of science and principles that
recognized the importance of practical understandings in scientific practice were inspirational to
me. The practice study methodology incorporates this inspiration and the learning from his
works and other sources he introduced to me. I hope to refine the application of this
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methodology in my future work. I also appreciate the support of my law firm through this period
of transition and the experiences I have been offered to be in leadership roles among
professionals in practice. My learning over the past six years has been marked by a persistent
interplay of theoretical work and my practical, sometimes frustrating, work as a practice group
leader and firm strategist. This dissertation has been shaped by that interplay.
I also owe a debt of gratitude to participants in this dissertation research project. My
special thanks go to Dr. Rachel C. Hess, Kim Bowman, and Lauren Kirwan, the HSIR
organizers, who allowed me to gain and share some insights from their organizational lives. I
was inspired by their work and the work of others at the University of Utah to transform health
care and academic medicine. I also greatly appreciated the time and contributions of other
interview participants. As contemplated by the methodology, my research was significantly
enhanced by obtaining multiple perspectives. Dr. Hess addressed the most significant obstacle to
this entire project—obtaining access to a site that would allow some in-depth exploration. I
thank her for her commitment to this particular form of health services research. I also have
appreciated the contributions of my daughter Elizabeth Ellison and her husband Brian Chappell,
Ph.D. for their sensitive editing and significant input on style and content. My practice assistant
Renee Esson also has played an important role in dealing with my drafts and research. But my
greatest supporter is my partner Sue, who has never questioned any part of my entire Ph.D.
venture while she has patiently awaited starting the next phase of our life together.
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Abstract
Transformation of health care systems will be grounded in new professional relations and
collective, cross-disciplinary actions to impact care delivery. Organizing such relations and
actions involves practical inquiry rather than applying professional knowledge. This dissertation
presents an exploratory, performative study of the initial organizing of the Health Systems
Innovation and Research (HSIR) Program in Health Sciences at the University of Utah. The
HSIR program was conceived principally to catalyze cross-disciplinary innovation and health
services research and enhance care delivery changes by documenting care improvements and
publishing research. This study includes a composite narrative of the organizing and practical
inquiry work of HSIR organizers, which highlights many questions, issues, possibilities, and
priority shifts that would likely face those who would seek to transform care delivery and the
cultures of academic medicine. The study identifies improvement, integration, and
transformative strategies as pathways to effect change in health systems. The study includes a
narrative-based analysis of cultural, dynamic, and narrative resources to enhance understanding
of the HSIR story and the implications of cultural and dynamic influences for the Program’s
future and health systems transformation. This analysis emphasizes the cultural and dynamic
influences of academic and clinical departments and other sources of dynamic influence that
were operating to hinder or facilitate the larger objectives of HSIR organizers. The study also
explores the significance of collective practical inquiry, exploratory inquiry, and culture change
to the practice and theory of leadership and change. The HSIR study was conducted using a
practice study methodology developed from practice and narrative theories, with contributions
from complexity, process, learning, organizing, social construction, and relational theories and
empirical studies of professionals undergoing change. The methodology recognizes an
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expansive, relational complex of practice as the empirical world to be studied, and was designed
to explore practical inquiry, organizing, and collective actions of professionals in changing
organizational situations. Methodological design principles focus data collection and analysis on
situated activities, local discoveries, practical understandings, dynamic and cultural influences,
narrative connections, future possibilities, and significant matters identified by practice
participants. The electronic version of this dissertation is at Ohiolink ETD Center,
http://etd.ohiolink.edu and AURA, http://aura.antioch.edu/
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Table of Contents
Acknowledgements ......................................................................................................................... i
Abstract ......................................................................................................................................... iii
List of Tables ................................................................................................................................ ix
List of Figures ................................................................................................................................ x
Preface........................................................................................................................................... xi
Introduction .................................................................................................................................... 1
Introducing the Health Systems Innovation and Research Program ...................................... 4
My Story and Positioning ....................................................................................................... 8
Framing a Study of the Health Systems Innovation and Research Program .......................... 9
Practical Inquiry and Organizing—Taking an Inside-Out View of Health
Systems Transformation. .......................................................................................... 10
Organizing Within the Relational and Cultural Complexes of Practice. ....................... 13
Developing a Practice Study Methodology ................................................................... 17
Summary of the Chapters ..................................................................................................... 31
Review of Literature .................................................................................................................... 33
Cultural Resources in the Study of Practice ......................................................................... 34
Practice as Professionals Organizing Emerging Collective Culture ............................. 34
Practice as Culture; Culture as Practice—Part 1 ........................................................... 35
Practice Theories and Related Literature ...................................................................... 38
Professionals and Professional Learning ....................................................................... 56
Organizing as Processes of Organizational Becoming .................................................. 69
Emergence and Uncertainty .......................................................................................... 73
Collective Action and Outcomes as Relational and Social Construction ...................... 76
Meaning and Significance as Cultural Construction ..................................................... 90
Summary of Practice-Related Theories ....................................................................... 100
Dynamic Resources in the Study of Practice ...................................................................... 102
Identifying Examples of Professionals Responding to Changing Organizational
Situations ................................................................................................................ 103
Representative Empirical Studies ................................................................................ 105
Thematics of Visible Performances and Dynamic Influences..................................... 111
Using Empirical Studies of Professionals to Understand Practice Dynamics ............. 133
Narrative Resources in the Study of Practice ..................................................................... 140
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Narrative Research ...................................................................................................... 141
Narrative Linking ........................................................................................................ 145
Narrative Connections ................................................................................................. 149
Reading and Narrative Interpretation .......................................................................... 155
Reading for Broader Implications ............................................................................... 157
Developing a Practice Study Methodology ............................................................................... 160
Exploring the Empirical World of Practice ........................................................................ 161
Ontological and Epistemological Considerations ....................................................... 162
Methodological Design Principles .............................................................................. 165
Employing Methodological Design Principles in an Exploratory Study of HSIR
Organizing...................................................................................................................... 179
Level of Analysis ......................................................................................................... 179
Exploratory Research Involving Practical Inquiry and Organizing ............................ 180
Interpreting and Analyzing the Data ................................................................................... 191
Handling Interview Data ............................................................................................. 193
Creating a Narrative of HSIR Organizing ................................................................... 195
Developing Research Interpretations Through Reading ............................................. 196
Building a Learning Health System ........................................................................................... 200
Are We Asking the Right Questions? ................................................................................. 201
“Does the U Have a Winning Hand?” ......................................................................... 203
Algorithms for Innovation ........................................................................................... 207
The Proposal for a Health Services Research Center .................................................. 211
What Is at Stake in the Success of the Health Systems Innovation and Research
Program ................................................................................................................... 216
HSIR Leadership ......................................................................................................... 220
Breakfast, Lunch, and Dinner ...................................................................................... 223
The First Interview: Understanding in the Position of an Organizer .......................... 228
PTSD: Are We Addressing the Right Problems? ............................................................... 236
Developing an Action Agenda .................................................................................... 237
Emerging Issues and Problems .................................................................................... 239
Evaluating HSIR’s Progress ........................................................................................ 268
Toward Health Systems Transformation Through Virtuous Cycles of Learning ............... 273
Building a Practice in Health Systems Innovation and Research ................................ 274
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