Journal of Health Organization and Management The rules of engagement: physician engagement strategies in intergroup contexts Sara A. Kreindler Bridget K. Larson Frances M. Wu Josette N. Gbemudu Kathleen L. Carluzzo Ashley Struthers Aricca D. Van Citters Stephen M. Shortell Eugene C. Nelson Elliott S. Fisher

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Article information: To cite this document: Sara A. Kreindler Bridget K. Larson Frances M. Wu Josette N. Gbemudu Kathleen L. Carluzzo Ashley Struthers Aricca D. Van Citters Stephen M. Shortell Eugene C. Nelson Elliott S. Fisher , (2014),"The rules of engagement: physician engagement strategies in intergroup contexts", Journal of Health Organization and Management, Vol. 28 Iss 1 pp. 41 - 61 Permanent link to this document: http://dx.doi.org/10.1108/JHOM-02-2013-0024 Downloaded on: 31 January 2016, At: 06:23 (PT) References: this document contains references to 30 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 776 times since 2014*

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The rules of engagement: physician engagement strategies in intergroup contexts Sara A. Kreindler, Bridget K. Larson, Frances M. Wu, Josette N. Gbemudu, Kathleen L. Carluzzo, Ashley Struthers, Aricca D. Van Citters, Stephen M. Shortell, Eugene C. Nelson and Elliott S. Fisher

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Information about the authors can be found at the end of the article Abstract Purpose – Recognition of the importance and difficulty of engaging physicians in organisational change has sparked an explosion of literature. The social identity approach, by considering engagement in terms of underlying group identifications and intergroup dynamics, may provide a framework for choosing among the plethora of proposed engagement techniques. This paper seeks to address this issue. Design/methodology/approach – The authors examined how four disparate organisations engaged physicians in change. Qualitative methods included interviews (109 managers and physicians), observation, and document review. Findings – Beyond a universal focus on relationship-building, sites differed radically in their preferred strategies. Each emphasised or downplayed professional and/or organisational identity as befit the existing level of inter-group closeness between physicians and managers: an independent practice association sought to enhance members’ identity as independent physicians; a hospital, engaging community physicians suspicious of integration, stressed collaboration among separate, equal partners; a developing integrated-delivery system promoted alignment among diverse groups by balancing “systemness” with subgroup uniqueness; a medical group established a strong common identity among employed physicians, but practised pragmatic co-operation with its affiliates. Research limitations/implications – The authors cannot confirm the accuracy of managers’ perceptions of the inter-group context or the efficacy of particular strategies. Nonetheless, the findings suggested the fruitfulness of social identity thinking in approaching physician engagement. Practical implications – Attention to inter-group dynamics may help organisations engage physicians more effectively. Originality/value – This study illuminates and explains variation in the way different organisations engage physicians, and offers a theoretical basis for selecting engagement strategies. Keywords Managers, Qualitative research, Change management, United States of America, Social identification, Doctors Paper type Research paper

1. Introduction Physicians are arguably the most powerful actors in the healthcare system, both as providers and often as business units. Change in healthcare hinges on physician The authors gratefully acknowledge the financial support of The Commonwealth Fund; the funder had no role in the research process. The authors also thank Reena Kreindler for her editorial advice and transcription services, and Lisa Gray for additional transcription.

Journal of Health Organization and Management Vol. 28 No. 1, 2014 pp. 41-61 q Emerald Group Publishing Limited 1477-7266 DOI 10.1108/JHOM-02-2013-0024

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engagement – doctors’ willingness to alter their behaviour and to involve themselves in the process of change (Hroscikoski et al., 2006; Nutting et al., 2010). The difficulty of engaging physicians has sparked an explosion of literature on tactics for promoting this elusive yet critical goal: from incentives to identification of champions, performance monitoring to participatory meetings (Grimshaw et al., 2006; Sears, 2011; Taitz et al., 2011). However, a crucial aspect of the problem is seldom made explicit: physician engagement is not merely a matter of engaging individuals, but of engaging members of a group, who are likely to be highly identified with their profession, attached to its defining attributes and norms, and motivated to protect its power and status (Kreindler et al., 2012a). It always involves an inter-group interaction between physicians and administrative leaders, who typically share membership in a superordinate group (the parent organisation), with which physicians may or may not identify. Moreover, it often involves numerous nested and cross-cutting groups (primary care, specialists, particular specialties, hospitals, departments, practices, etc.) To bring coherence to the plethora of physician engagement strategies, a theoretical framework is needed that can account for underlying group and intergroup dynamics. The social identity approach (SIA, comprising social identity theory and its extension, self-categorisation theory; Tajfel and Turner, 1979; Turner et al., 1987) offers such a framework. The SIA was founded in the insight that the self-concept comprises not only unique individual characteristics (personal identity) but group memberships (social identity). It explores how relations within and between groups are conditioned by the social structure in which groups interact, the identity content by which groups define themselves, the context (which can alter the salience of various group identities), and group members’ strength of identification. The latter topic has been particularly prominent in the management literature; a large body of research has linked organisational identification to myriad positive outcomes, including improved motivation, productivity, communication, organisational citizenship, and intent to stay (e.g. Dukerich et al., 2002; Haslam, 2004; Randsley De Moura et al., 2009). Leaders can draw on employees’ shared identity to drive change, by highlighting an innovation’s congruence with valued identity content (Haslam et al., 2011). However, organisational identification cannot be taken for granted – especially when personnel are deeply committed to some other work-related group. This is often the case with physicians: Although high professional and organisational identification can coexist, physicians’ professional identification tends to be the stronger (Bartels et al., 2010). Furthermore, doctors who identify strongly with their profession and weakly with the organisation – or worse, see managers as an out-group with antithetical values – tend to repudiate management influence and organisational change (Hekman et al., 2009). Physicians’ organisational identification is linked to how attractive they find the organisation’s identity content (Dukerich et al., 2002). It may also be promoted by inclusive management practices (Bartels et al., 2010); however, direct efforts to stimulate it through appeals to unity may backfire by threatening physicians’ professional identity (Fiol et al., 2009). Complicating the picture may be identity-based conflicts among professional groups, including subgroups within medicine (Hewett et al., 2009). (For a detailed review of the SIA and its application to healthcare, see Kreindler et al., 2012.) Sociological and organisation-studies research (e.g. Doolin, 2004; Reay and Hinings, 2009) has documented the failure of managerial attempts to “engage” physicians

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through strategies that ignore power and status relations (in SIA terms, social structure) and groups’ conflicting worldviews (identity content). Yet there has been little theory-informed analysis of how managers can take such social phenomena into account. The present article, drawing on data and theory, offers a conceptual basis for distinguishing among different engagement strategies and identifying which might be most appropriate for different social identity landscapes. Focusing on four disparate organisations that had demonstrated some success at engaging physicians, we asked: what engagement strategies do managers employ, and how do these respond to the intergroup context? 2. Methods This study’s context was the implementation of a new American model of healthcare integration, the accountable care organisation (ACO; for findings pertaining to ACOs, see Kreindler et al., 2012b). In this increasingly popular model, providers across the care continuum agree to be responsible for a population of patients; if they succeed in meeting quality targets while reducing costs, they receive a share of the savings. Our study focused on four nascent ACOs chosen by the Brookings-Dartmouth ACO Collaborative: (1) Monarch Healthcare, a California Independent Practice Association (IPA); (2) Tucson Medical Centre (TMC), an Arizona hospital engaging community physicians; (3) Norton Healthcare, a Kentucky integrated-delivery system; and (4) HealthCare Partners (HCP), a combined medical group and IPA in California. Selection as a pilot site implied strong past performance and high perceived likelihood of successful ACO formation; sites reflected a diversity of organisational forms and local contexts, but each had a solid record of implementing initiatives to manage and improve care, and of mustering sufficient physician support to do so (see Larson et al., 2012). Physician engagement is highly important to ACO development, which typically requires physicians to join a new organisation and/or collaborate in new ways, However, inasmuch as participants described ACO-related engagement strategies as an extension of longstanding efforts, we considered physician engagement in totality, whether or not ACO-related. We undertook two- to five-day visits at each site, led by a Brookings-Dartmouth researcher who focused on technical/structural aspects of implementation (BL) and an independent researcher who focused on social aspects (SK). We requested access to personnel representing a variety of professional roles (specialist/primary care/non-physician), organisational levels (senior/middle/non-manager), and attitudes (ACO proponent/sceptic); each organisation arranged access to individuals and pre-existing groups (e.g. steering committees) who could speak to the developing ACO. We conducted semi-structured individual and group interviews with representatives of each parent organisation – largely senior and upper-middle managers (Monarch: 12, HCP: 14, TMC: eight, Norton: 24) and members of physician groups (Monarch: 15, HCP: 21, TMC: nine, Norton: six; depending on the site, this included employed, affiliated, and external primary-care and specialty physicians, and practice managers).

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Interviews, typically lasting 30-60 minutes, included open-ended questions related to engagement (e.g. “How would you describe your organisation’s relationship with physicians?”; “How are you engaging physicians in the ACO?”) and other topics; participants frequently raised the issue of physician engagement before we mentioned it, and most discussed it at length. We also observed ACO-related meetings and reviewed relevant documents, including organisational websites. Interviews were audio-recorded and transcribed, and extensive field notes taken. The study received approval from the University of Manitoba Health Research Ethics Board. Participants were informed of the study’s purpose (to understand organisations’ early experiences with ACOs) and signed consent forms; all but one agreed to have the interview recorded. To protect confidentiality, transcripts were anonymised and recordings subsequently destroyed. Analysis was an iterative process that began during data collection; formal coding commenced when the transcripts were ready. To reduce interpretation bias, we identified themes inductively through the constant comparative method (Strauss and Corbin, 1998) and did not incorporate theoretical constructs until midway through the process. Coding was done by one site visitor (SK) in consultation with the others. Through open coding and initial rounds of axial coding, we arrived at a list of themes that described engagement strategies (e.g. communication, input, incentives, etc.) and other aspects of intergroup relationships (e.g. co-operation, conflict), without reference to the SIA. Next, we considered the preliminary findings through a social identity lens. We noticed first that participants’ statements implied different degrees of inter-group closeness between physicians and managers; then, that this varied systematically by site. To probe this pattern further, we invoked two SIA-based models of intergroup relations in organisations. The “ASPIRe model” (Actualizing Social and Personal Identity Resources; Haslam et al., 2003) outlines a process for engaging staff (first in identity-based subgroups, then collectively) in building a mosaic identity that incorporates each group’s unique contributions. The Intractable Identity Conflict (IIC) model outlines how groups that see each other as a threat may progressively attain secure separate identities, then partnership, and ultimately integration (Fiol et al., 2009). Both models are grounded in theory that is well-supported by basic and applied research (Haslam, 2004), and ASPIRe has begun to gain empirical support as an organisational-development approach (Peters et al., 2013). Both posit that higher stages of inter-group closeness cannot be achieved before lower ones, and that strategies geared to a higher degree of closeness than currently exists are likely to backfire. For example, if physician-management relations are adversarial, managers’ invocation of shared organisational values may provoke identity threat and only fuel hostility. We realized that these stage theories could also be applied cross-sectionally to identify organisations’ strategies for managing intergroup relationships. Drawing on both the models and our data, we identified a continuum of such strategies, which ranged from not promoting any relationship, through promoting increased degrees of inter-group closeness, and finally to affirming a common identity subsuming all groups. Table I presents the final version of the continuum, along with the roughly corresponding ASPIRe and IIC stages. We developed a theory-based coding scheme to identify data that confirmed or denied the use of each strategy or otherwise pertained to intergroup relations. The primary coder applied this coding scheme to all data, refining it along the way, then

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Strategy

Definition

0. Individualism Focus on personal, not social, identity by emphasising individualistic interests and rewards 1. Pragmatic Cooperate with another group for cooperation mutual gain, while maintaining a neutral or somewhat adversarial relationship 2. Relationship- Build a positive relationship with building another group through outreach, twoway communication, and helpfulness Affirm another group’s identity by 3. Supporting supporting its norms, values, and subgroup opinion leaders identity 4. Intergroup Promote collaboration towards shared partnership goals, but without demanding that the two groups share an identity 5. Promoting Emphasise both subgroup identities dual identity and a shared, superordinate identity such as that of the parent organisation Emphasise a shared, superordinate 6. Promoting identity without also emphasising common subgroup identities identity

ASPIRe

IIC

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Readiness

45 Assessing identity resources Subordinate caucusing Superordinate consensualising Organic goalsetting

Mindfulness Positive in-group distinctiveness Simultaneous intergroup differentiation and unity Integrative goals and structures

trained a naı¨ve coder (AS) who coded 10 per cent of the data (randomly selected four-page segments of transcripts). Coders met at regular intervals to identify disagreements, resolve these by consensus, and clarify the coding guide accordingly; the primary coder re-coded all relevant extracts each time a revision occurred. Interpretations were tested against the data, with attention to both confirmatory and deviant cases, then discussed by the full team and checked with key informants. Through this process, we built up a picture of each site’s inter-group landscape, the extent to which each strategy was applied, and the physician response. We developed a sense of prevailing physician-organisation relationships by triangulating data from manager and physician interviews, along with information gleaned from documents and observation. We identified sites’ primary strategi(es) by noting how many managers cited a strategy, how deeply they discussed it, and how unequivocally they advocated it. In doing so, we focused on how managers intended their strategies, without making assumptions about how their actions were received or interpreted by physicians. However, we also gained some understanding of the physician response from physician interviews and observation. 3. Results For each site, we describe physician-organisation dynamics, the prevailing engagement strategies (see Table II), and their apparent strengths and weaknesses in terms of furthering the organisation’s goals. Owing to length restrictions, we present only a sampling of relevant quotations; each primary strategy was reflected in many other extracts.

Table I. Continuum of engagement strategies

Table II. Physician engagement strategies emphasised at each site

Monarch TMC Norton HCP

Yes Somewhat Somewhat Yes

Specialists only No No Primary strategy: IPA

Primary strategy Yes Yes Yes

2. Relationshipbuilding Primary strategy Yes Yes Somewhat

3. Supporting subgroup identity

No Primary strategy Yes No

4. Intergroup partnership

No No Primary strategy No

5. Promoting dual identity

No No Yes Primary strategy: staff model

6. Promoting common identity

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0. 1. Pragmatic Individualism cooperation

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3.1 Monarch 3.1.1. Intergroup context. Monarch represented 760 primary-care physicians (PCPs) and 1,640 specialists in private practice. Although a handful of its physicians were employed, Monarch remained fundamentally an IPA, and devoted substantial energy to “constant education, constant contact [. . .] trying to build that relationship” with independent PCPs. Monarch was beginning to engage specialists in its ACO, building on strong relationships with certain capitated groups. Informants differed on how PCPs felt about Monarch; managers tended to accentuate the positive, while some non-Monarch participants said physicians felt “resentment” about having to depend on an IPA. Physicians’ level of engagement was said to vary both individually and regionally. Although the PCPs we interviewed praised Monarch, they did not necessarily identify with it. One reported “a pretty close relationship” but still referred to Monarch as “them”, pointing to actions that “help[ed] them as well as us”. Even the testimonials posted on Monarch’s website implied a mutually beneficial association, not shared group membership (“It has invested its resources into developing systems to help me”). Such attitudes contrasted with those expressed by corporate staff, who evinced strong identification (“Monarch, for me, is my home. I cannot ever imagine working for another organisation”). Managers recognised that physicians did not share such attitudes. One told a story in which a physician expressed an “incredible sense of personal pride, personal pride that he was part of Monarch”; however, the very importance attached to this second-hand tale suggested that physicians’ organisational identification was the more prized for its rarity (“I thought, wow! [. . .] I mean, that’s what we live for”). 3.1.2 Prevailing strategies. Monarch’s engagement of PCPs depended on relationship-building; managers reported tireless outreach, assistance, and two-way communication: [W]e are very much of a relationship organisation. So the first thing we did is we set up meetings. We went out to our major groups, one-on-one, and we did dinners with presentations . . . . . . the Medical Leadership Council [. . .] is getting engaged with Monarch [. . .] we respect the opinions of those physicians in that body.

However, Monarch’s most distinctive engagement strategy was supporting subgroup identity. Managers described promoting physician champions who were sufficiently representative of physician identity. When a hospital executive or a researcher or a politician or any business-person tries to tell a doctor what to do or why they oughtta do it, they don’t embrace it [. . .] And so you’ve gotta have physician leaders – so that’s the first step in physician engagement. The second step is you’ve gotta have physician leaders who are respected within the medical community [. . .] you can’t parachute someone in from New York and say, “Here is your physician leader now”.

Managers also emphasised Monarch’s status as physician-owned and “physician-centric”, a message echoed by several PCPs: [It’s] owned by doctors; doctors do the utilisation [review]. We all own a piece of Monarch [. . .] If [a procedure] needs to be done, it’s gonna get approved, it’s not going to be, “Sorry, that’s it”. Because there are doctors on the other end that understand.

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Monarch’s focus on physician identity was enshrined in its mission statement: “To help physician partners advance medical excellence in the communities we serve”. Efforts to mobilize physician identity-content – including the norm of autonomy – were most obvious on Monarch’s website, which invited “independent-thinking doctors in independent practice” who “share the same philosophy of excellence” to join “an elite group of professionals”. Appeals to prospective physicians stressed how everything about Monarch – from its “patient-first” philosophy to its extensive use of technology – flowed from physicians’ core values (e.g. the electronic referral system “takes care of business so you can concentrate on medicine”). Some managers also pointed to the importance of individualistic strategies, such as pay-for-performance (P4P). However, when individualism was mentioned, it was often portrayed as consistent with physicians’ identity and collective wishes: Doctors are doctors – you know, I can say that ’cause I’m a doctor, and the first thing that they’re gonna always wanna know is, what does it mean to my pocket, and the second thing is how much work is it gonna be.

Monarch’s engagement strategy did not include an emphasis on intergroup partnership. We only once heard a physician express intergroup sharedness (“[The physician advisory committee] really leads to a better relationship [. . .] rather than us against them, it’s now us”); we never heard a manager do so. Nor did we hear about efforts to transmit Monarch identity to PCPs, aside from one manager’s fairly weak statement that during outreach dinners, “we’ll try to reinforce the mission statement and that type of thing”. On Monarch’s website, its mission and values were not posted, and an “executive updates” link was perennially inactive. The corporate colour was prominently used for key words and phrases – but often those that stressed physician identity and autonomy (e.g. “independently” in “Monarch means practicing medicine the way you want to. Independently”). To the extent that a common identity was promoted at all, it was a medical, not a Monarch identity. To engage specialists, managers relied on pragmatic co-operation, describing cautious collaboration in a difficult intergroup context: The selling point is that you can either become part of this new paradigm, and have the volume [. . .] [or] not be part of this paradigm, and have a lower reimbursement and a lower volume. So, it’s a tough message [. . .] but we are engaging them, and we realize we need specialists.

Although Monarch’s communication to specialists often emphasised individualism, it also wooed specialists by supporting physician identity. Asked by a specialist how Monarch envisioned specialty groups’ participation in the ACO, a senior manager replied, “We are a delivery system of physicians” (emphasis added), explaining that this meant being “fair and balanced” with primary and specialty care. Even specialists who expressed little interest in joining Monarch’s ACO agreed that physician ownership was a major point in its favour. No one expressed intergroup partnership, much less a common identity between specialists and Monarch – although specialists sometimes spoke in such terms about collaborating specialty groups “a group of community-spirited docs [have] come together”). 3.1.3 Strengths and weaknesses. Physicians appeared to find Monarch’s efforts to support physician identity both credible and valuable, and offered their support in

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return. However, there seemed to be limits to what Monarch could achieve through this strategy. When goals that were in the interests of the larger organisation could not be easily linked to physician norms, Monarch’s subgroup-supporting strategy gave it no basis for “identity leadership” (cf. Haslam et al., 2011). For instance, some PCPs reported picking and choosing among performance metrics, meeting those that accorded with their identity as primary-care physicians and ignoring the rest (“Prescribing generics I don’t really look at, I don’t care [. . .] Things like making sure [. . .] colonoscopies [are done] [. . .] especially being primary care I very much believe in all of that”). Ironically, one manager identified generic prescribing as Monarch’s leading opportunity for cost savings. 3.2 TMC 3.2.1 Inter-group context. TMC, a non-profit, 615-bed community hospital, was developing an ACO with local physicians. It maintained a small employed practice, but eschewed any large-scale strategy of employment since a 1990s experiment with an integrated system, which had provoked “physician rebellion” and collapsed. TMC had a strong relationship with one local private practice, but had just begun to engage a large “group practice without walls” whose participation was deemed critical. Participants within and outside TMC reported that over the past three years, the hospital had made physician engagement a priority. They explained that the previous administration had alienated physicians (“we had a single-digit score on our physician satisfaction survey”), and the current administration had made major efforts to repair hostile relations (as a specialist leader recounted, “there was a change in leadership and things got much better [. . .] I would characterise TMC as being the most physician-friendly in town”). Participants described the hospital’s current relationship with physicians as generally positive – several co-management agreements (in which the hospital and specialists jointly managed a service line and shared its revenues) were flourishing, and some PCPs were well-aligned with TMC; however, managers suggested that considerable work remained to be done (“Well, in our community, even a closely aligned physician isn’t”). 3.2.2 Prevailing strategies. TMC’s most distinctive engagement strategy was inter-group partnership, an approach that the new administration had established early on: [W]e started looking for ways to align ourselves with the doctors and say, where’s the common ground . . . (Manager). [TMC] stopped looking at physicians as adversaries, and really were looking more for a collaborative approach [. . .] And it wasn’t us and them, it was let’s see [. . .] if we can make it us (Specialist Leader).

TMC strongly emphasised sharing power with physicians, planning to give them a majority on the ACO’s governing board, with only 20 per cent representation for the hospital. Physicians agreed that the ACO would be “physician-driven”; specialists also noted TMC’s positive co-management record. Participants advocated partnership over either a transactional (exchange-based) approach or the enforcement of a superordinate identity. Our strategy had to do with, how do you build the physician relationship as partners – not as quotes “customers” (Manager).

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In the past, what we would’ve talked about is, why isn’t the hospital doing more for me [. . .] you know [. . .] me, me, me [. . .] [Now,] we had conversations about what can physicians and the hospital do together to improve the environment of care. Collective (Manager). It’s a partnership rather than a “we own you” model (Specialist Manager).

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Managers suggested that TMC’s co-management agreements had begun with pragmatic co-operation (“[A specialist] realized that the vendor was making more than him. So they came to us and said, ‘Something’s not right here’”) but evolved into intergroup partnership “[It’s] a different level of conversation when you’re talking about how do we manage this together. And it’s not you, or it’s not me – it’s us”). A specialist leader echoed, “It is rare that any number with a dollar sign in front of it is ever discussed at a [service-line agreement] meeting”. Participants also emphasised relationship-building through two-way dialogue (“building relationships, communicating with people, asking them what they needed, having town halls”). Support for subgroup identity was also evident: Physician champions spearheaded the engagement of new physicians in the ACO, and one executive alone cited five elements of physician identity-content that could be mobilized in the service of change (e.g. “very entrepreneurial nature”, “desire to take better care of patients”, “naturally competitive”). Managers also specifically supported PCP identity, stressing “the tremendous value [of] the primary care physician”. While some participants alluded to individualistic “incentives” as a driver of change, they more strongly emphasised physician values. Managers attributing financial motivation to physicians overwhelmingly mentioned it in tandem with altruistic norms (“Although physicians are obviously economically driven, they also want to do the right thing for their patients”). TMC’s engagement strategies appeared to culminate in inter-group partnership: Whereas Monarch used relationship-building and support for subgroup identity as an alternative to inter-group sharedness, TMC used them to promote it. Leaders stopped short of offering TMC as an identity object; as one explained, “Our doctors [. . .] never signed on to be employees [. . .] so we actually coined this phrase about three years ago that said, TMC will be the hospital of choice for physicians who have a choice”. 3.2.3 Strengths and weaknesses. Physicians seemed to recognise and appreciate TMC’s partnership approach, which was credited with a rapid improvement in hospital-physician relations. However, TMC’s eagerness to share power with primary care raised some concerns among specialists (“[The ACO] is driven right now by the primary guys [. . .] how do they integrate the specialists into this?”) Some managers also questioned whether local physician leadership capacity was adequate to support effective partnership. At an ACO meeting, we observed that the atmosphere was collegial but not orderly – there was no clear agenda, and no action items were generated; managers, however, seemed reluctant to take control of the discussion. TMC’s approach seemed to depend on devolving significant authority to a group with limited organisational capacity. The state of physician leadership may have improved when the position of Chief Medical Officer was filled, shortly after our visit. 3.3 Norton 3.3.1 Inter-group context. Norton’s integrated delivery system included five non-profit hospitals, a cancer institute, and a network of physician practices; service lines cut

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across facilities in a matrix structure. Physician engagement took place in the context of a “journey” towards integrating numerous professional and institutional identities into one system:

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Manager: There’s a little bit of a mentality out there around “we”/“they” [. . .] In their mind, at the facility, we’re the “we” [. . .] And the “they” is the system [. . .] But on any given day it could be “we” is Norton Suburban and “they” is Norton Hospital. It could be on any given day “we” is the physician practice and “they” is the inpatient nursing units . . . Interviewer: And for the staff and physicians [. . .] is Norton Healthcare ever “we”? Manager: Yes [. . .] We are a “we” most of the time, but for me to sit here and say that we’re a “we” 100 per cent of the time, we’re not.

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Participants reported that both physician and hospital alignment had increased markedly over the past seven years, but could still improve (“[We’re] becoming much, much more of a system since I’ve been here [. . .] I still see elements that aren’t systemness”). Employed physicians made up 25 per cent of Norton’s 2,000-member medical workforce. Participants described Norton as a “leader” in employing physicians, explaining that many local physicians wanted to be employed. Several managers thought employment promoted engagement (“it has aligned certain goals”), although others questioned how strongly even employed physicians identified with Norton (“I was a university professor [. . .] I’ve always used that as an analogy for [being] a physician [. . .] [M]y loyalty was not to the university, it was to my discipline [. . .] ‘You may think I’m your employee [. . .] that’s not my view of myself or my job’”). 3.3.2 Prevailing strategies. Norton’s preferred engagement strategy was promoting dual identity, enabling physician practices and hospitals to retain unique identities within the broader organisation. Each facility does have its own identity – in a healthy way [. . .] but at the same time everybody understands we’re trying to move to standards of practice (Manager). We can standardize certain processes but still allow individuality where it’s needed, and we see that throughout our system because each institution has its own individual nature (Hospital Manager).

A senior manager described Norton’s approach as a happy medium between fragmentation and over-centralisation, concluding “We [. . .] have kind of moved to the middle and understand how we need to function as a system [. . .] but also allow local autonomy”. Physician leaders agreed with this assessment, contrasting Norton’s model with “a really controlled environment [. . .] [where] you were really a ‘doc in a box’”. The principle of dual identity was enshrined in Norton’s matrix structure, which required consensus-building among diverse hospital and professional groups. When managers used the language of common identity (advocating “systemness”, “standardisation”, or “integration”), they balanced it by invoking inter-group partnership or subgroup autonomy (“Everybody has a voice”; “It’s not that we’re going to tell [physicians] how to practice”). This balance further exemplified the theme of dual identity. Relationship-building was heavily emphasised (“Multiple town hall meetings”; “basing our decisions on their feedback”); as one manager stated, “the people who report to me [. . .] are tired of [hearing] [. . .] ‘Tell me the physician relationships you’ve

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worked on this week’”. Managers recounted how the data team had built “credibility with our physicians” through ongoing outreach, transparency about Norton’s own performance, and willingness to involve physicians in improving the data. Managers also supported subgroup identity by linking quality improvement to physician norms (“all providers want the right information at the right time so they can make the best decisions”) and nurturing physician leaders. They reported increasing efforts to engage physicians earlier and more meaningfully, moving beyond after-the-fact feedback and token “champions” to making physicians “part of the team that created [the] initial solution” and “mentoring” them to take leadership roles. Relationship-building and support for subgroup identity buttressed Norton’s overall strategy of promoting dual identity (“[The] committee had physicians from every hospital [. . .] so it truly became a system initiative”). Although financial incentives formed part of Norton’s approach, respondents did not emphasise individualism. While a frontline PCP openly stated, “I think reimbursement’s huge – and less work”, managers trod more lightly (“There’s a very elastic connection between [. . .] payments and physician behaviour [. . .] but it gets your attention”). 3.3.3 Strengths and weaknesses. While highlighting Norton’s progress towards integration, managers described the “journey” as incomplete. Some physicians’ statements implied ongoing intergroup tension; for example, a PCP wondered whether hospitals would dominate Norton’s ACO, leaving primary care “at the bottom of the food chain”. Managers relied on a dual-identity approach to bring highly identified subgroups into unity. The limitations of this approach were manifest in the slowness and complexity of implementing change in a matrix system (“checking with everybody before you can make a move”; “it’s sort of like the United Nations getting work done around here”). However, participants also felt that the matrix was “a key part of our success model” because it “force[d] collaboration”, ensuring genuine “buy-in” and a “strong and foolproofed” end product. Most enumerated both pros and cons, but ultimately supported the model (“I think it works for us somehow”). 3.4 HCP 3.4.1 Inter-group context. HCP, which began its 30-year history as a medical group, employed about 650 physicians (300 PCPs, 100 hospitalists, 250 specialists); it also had an IPA of 2,400 affiliates, representing a roughly equal proportion of patient contacts. Managers called the group practice and IPA “different worlds”, characterizing employed physicians as highly identified (“everybody has a HealthCare Partners shirt, t-shirt, underwear”) and easier to control (“more compliant”, “more regimented”). It was taken as self-evident that IPA physicians, “by definition”, did not identify with HCP (“they’re IPAs for a reason, you know”). Their relationships with HCP were said to range “from, they love us and they think we’re wonderful, to, you don’t even say the initials HCP when you’re in their presence”. Notwithstanding HCP’s efforts to improve these relationships, managers seemed to consider the IPA less central to the organisation. One explained that, historically, HCP was “really a group model [. . .] everything that dealt with the IPA was put in what we called the parking lot”; unlike Monarch, HCP had only recently introduced provider liaisons. Another noted that quality measures were reported separately for the group practice and IPA, both for precision and because “the IPA would drag us down”. On HCP’s website, both the

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IPA’s position on a list of “Our Companies” (last, after HCP itself, the medical group, an owned consulting firm, and a research institute) and the language used (e.g. “the IPA service area” vs “our service area” for the medical group) seemed to distance the IPA from the organisation. HCP did not arrange for us to visit any IPA practices. 3.4.2 Prevailing strategies. Primary strategies for engaging group-model and IPA physicians were radically different. For the former, managers emphasised promoting a common identity and culture (“it’s really the culture that runs that”; “more of a cultural nudge than a financial incentive”; “people wanna feel like they’re contributing members of a winning team”). The lone manager who opined that the transmission of culture could extend to the IPA acknowledged that this would be “slow” and “much harder to do”. For the IPA, managers described pragmatic co-operation: They are much more customers. They are, are you servicing them well with your information, with cash flow [. . .] it’s much more a customer service approach than an employment approach.

Managers stressed the importance of individualistic benefits for physicians in general (“it comes down to economic incentives”; “you have to get the WIFM [what’s in it for me] at the very beginning”). Relationship-building was also emphasised for employed and IPA physicians alike (“communication is the key”; “listening to them and giving them forums to speak out”). Like the other sites, HCP supported subgroup identity by using credible, locally chosen physician champions; moreover, some staff linked HCP’s values to its physician ownership (“The physicians are the owners and the partners, and that makes a difference [. . .] when you get to the bottom line, it’s patient care”). However, unlike Monarch, HCP did not treat medical identity as paramount. A senior leader who began by identifying himself as a physician and endorsing “clinician-led solutions” rejected a purely clinical identity for HCP (“we’re really a technology organisation that happens to be in healthcare”); similarly, HCP’s website balanced clinical and corporate rhetoric (“the doctors who lead this business venture”). Such constructions suggest that no subgroup identity took precedence over HCP’s common identity. HCP had a regional structure; however, the regions represented “geographic units”, not subgroup identities. Managers presented regionalisation as a useful form of decentralisation, not a means of promoting dual identity (“we have different business units that are designed to meet the local needs of the community”). The theme of intergroup partnership between HCP and any other group seemed completely absent. 3.4.3 Strengths and weaknesses. Managers emphasised how a strong common identity contributed to the success of HCP’s medical group. However, even our limited sample of three employed practices (Site A chosen for exceptional performance, B and C for proximity) revealed great variability in physicians’ organisational identification. Site A physicians embraced HCP identity, praising its leaders and philosophy (“it’s exciting working here because we have some amazing innovators up at the top”). Site B physicians spoke rather positively about HCP but primarily discussed individualistic concerns (“I think the key word is financial”). Site C physicians spoke of HCP’s common identity unfavourably (“we’re sheep”; “you are [. . .] a small part of a bigger machine”; “resistance is futile – you will be assimilated!”) Interestingly, at Site A, HCP identification was balanced by even stronger team identification; participants felt

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“very, very proud” of their clinic, and enthusiastically described its practices and “culture”. Site A leaders strove to “create a culture where people are not scared to mention new ideas” and avoid “a hammer approach”. Physicians valued this flexible, supportive leadership style as a counterweight to pressure from the central organisation; a top performer stated, “[it has] given me the freedom to not worry about those numbers so much, to really focus on what’s good for my patients, and then the numbers kind of worked itself out”. The oft-mentioned “teamwork” culture was observable during the group interview (with participants frequently expressing agreement and finishing each other’s sentences) and during a collaborative, productive meeting. The head physician affirmed: If people ask me what’s the secret to our success, I never talk about P4P, I never talk about [hierarchical condition categories], I don’t even talk about coordinated care [. . .] you have to create a place where you feel like you belong.

In contrast, Site C physicians showed little team identification; they disagreed on several issues, and spoke at length about HCP but almost never about their own clinic. We have no data on how IPA physicians responded to HCP’s transactional approach. However, HCP’s managers seemed to view IPA engagement as more “challenging” than did Monarch’s. 4. Discussion Strong emphasis on physician engagement was universal, as were generic relationship-building strategies such as two-way communication and participatory decision-making. Each site supported subgroup identity to some extent, by cultivating physician champions and drawing on physician norms (both altruistic and competitive). However, beyond the basics, physician engagement strategies varied dramatically by site and sometimes by physician subtype. In each case, the strategy was tailored to the specific intergroup relationship (which was shaped by regional culture and organisational history). Monarch, recognising that appeals to intergroup sharedness would be construed as threatening, aspired to be the organisation through which members expressed their identity as independent physicians. TMC, distinguishing its model from a failed integrated system in which physicians had felt dominated, advanced a vision of equal partnership. Norton, striving to bring diverse subgroups into harmony, promoted unity through diversity. HCP relied on a strong common identity in its group practice, but avoided addressing identity at all with its loosely affiliated IPA. Each strategy had its strengths and weaknesses: Monarch showed impressive ability to mobilize IPA physicians, but struggled to achieve organisational goals that lacked an obvious link to physician identity. TMC had a strong record of effective partnerships at the practice and service-line level, but the large-scale partnership deemed critical to the ACO had not yet coalesced. Norton made sustained progress towards integration, but had to accept a slow pace and cumbersome organisational structure. With its IPA, HCP clearly avoided identity threat, but also missed out on the benefits of harnessing social identity; in its group practice, a strong unitary identity contributed to excellent outcomes, but it was not universally embraced (which might be why managers also stressed individualism). Crucially, no strategy represented “best practice”; rather, different social contexts called for different strategies. For example,

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the choice of intergroup partnership over dual identity suited TMC’s intention to avoid an integrated system, but would not have served Norton’s efforts to advance one. Likewise, HCP, whose core business includes a group practice, could not adopt Monarch’s strategy of prioritising subgroup identity over its own. This study contributes to the literature on the intergroup dimension of physician-organisation relations (see Kreindler et al., 2012a) by demonstrating how organisations’ engagement strategies responded to the intergroup context. Consistent with the ASPIRe and IIC models (Fiol et al., 2009; Haslam et al., 2003), each site’s primary strategy corresponded to the prevailing level of physician-organisation closeness, and sites often undergirded this strategy with lower ones, but seldom jumped ahead. Managers differentiated between physicians who were employed, affiliated, and non-affiliated, using higher strategies where the formal physician-organisation connection was stronger. We also saw some evidence of intergroup relationships progressing along the continuum (cf. Reay and Hinings, 2009): At TMC, relationships with specialists evolved from pragmatic co-operation to partnership; at Norton, engagement of subgroups constituted a first step towards common practice. However, achieving a “high” stage may not always be necessary or feasible – at the 17-year-old Monarch, preserving the focus on subgroup identity was essential to maintaining the allegiance of independence-prizing physicians. While the literature suggests that identity-based leadership is more effective than purely individualistic or transactional approaches (Haslam et al., 2011), the question of which identiti(es) leaders should seek to mobilize – subgroup, shared, or both – seems to remain a question of context. The managerialist literature implicitly recognises the need for leaders to mobilize shared identities (McCarthy and Mueller, 2009); however, its undifferentiated recommendations imply that all identity-mobilisation efforts are equally credible (and benign). Critical perspectives often equate identity leadership with colonisation, to which the only possible responses are submission, resistance, or subversion (Doolin, 2004; Martin and Learmonth, 2012). Some organisation-studies research tempers this dismal view, showing that physicians can creatively reconstruct managerial discourses and technologies in ways that benefit medicine, management, and patients (Hotho, 2008; Levay and Waks, 2009). Our findings reveal that creative reconstruction is a two-way street; before implementing change, managers were already responding to the identities, social structures, and discourses in their organisational contexts. Their activities suggested not heavy-handed co-optation attempts, but willingness to engage with physician identities and adapt both the rhetoric and substance of change. The SIA-based continuum of strategies can elucidate which adaptations are appropriate to which conditions. For the purpose of understanding engagement as a social process, this continuum proved more useful than a literal taxonomy of engagement methods. The same method – for example, monitoring and feedback – can have very different implications, depending on whether the emphasis is on individual performance (individualism), dialogue with physicians (relationship-building), physician norms and peer influence (supporting subgroup identity), collaboration around shared values (intergroup partnership or dual identity), or standardisation (common identity). By furnishing a deeper understanding of how engagement approaches impinge on underlying intergroup dynamics, social identity thinking may help organisations choose and implement strategies more effectively.

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5. Limitations This study was both enhanced and limited by the relationship certain team members had developed with participating organisations through the Brookings-Dartmouth ACO Collaborative. This relationship greatly facilitated our access, making administrators more comfortable with our presence and generous with their time; however, it also introduced risk of bias. It would have been impracticable to coordinate interviews at these large, far-flung sites ourselves; however, relying on managers to recruit participants limited and biased our sample (although we retained input into the number and type of participants selected). Furthermore, while we strove to avoid biasing responses through our questions, we realized that our very identity could do so, since our affiliation with Brookings-Dartmouth connoted certain attitudes, knowledge, and “expertise”; another factor that may have affected responses was the presence of managers during certain interviews with staff or clinicians. Accordingly, we bore in mind that participants’ statements were made to an audience within a social context. We met frequently to reflect on how sample composition, participants’ expectations, and our own assumptions might have affected our interactions and impressions. We could not obtain a complete understanding of each site’s social dynamics, nor of how engagement strategies were experienced throughout the site; whereas we purposefully sampled participants who eschewed engagement in the ACO, our sample of physicians was neither large nor designed to represent varying levels of engagement with the parent organisation. We cannot assume that managers’ interpretations of their own strategies were universally shared by physicians, nor that their characterisations of physician attitudes were necessarily accurate. The important finding is that managers’ espoused strategies varied systematically with their perceptions of physicians’ social identifications. We also recognise that, insofar as it explores what managers can do to further organisational goals, this article takes a managerial standpoint. However, we do not mean to imply that organisational goals are inevitably desirable, that managers are unique in using social-identity management strategies, or that managers’ identities are “given” and uninfluenced by such strategies. Our limited sample of physicians precluded analysis of how they might be mobilizing social identities in their interactions with managers or other physicians (see Hotho, 2008; Levay and Waks, 2009; McDonald et al., 2006). Although the exploratory approach furnished a detailed understanding of each site’s context and preferred strategies, we cannot tell to what extent each site’s performance was attributable to its physician-engagement approach, or whether some strategies bore more fruit than others. The findings take us a step towards determining what works in what contexts, but longitudinal and mixed-methods research – including intervention research on theory-based engagement strategies – is needed to support conclusions. Finally, this examination of four sites cannot ascertain the prevalence of particular strategies or the existence of other variants; rather, it offers a window into the diversity and context-sensitivity of engagement approaches. 6. Implications These findings suggest several lessons for organisations seeking to engage physicians in new models of care, and in change more generally. First, relationship-building appears essential in laying the groundwork for positive intergroup relationships,

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whether the desired end is union or simply co-operation. However, beyond this foundation, the most appropriate strategy depends on intergroup context. In keeping with ASPIRe, organisations should begin with a thorough assessment of their “identity resources”: Which groups command a high degree of identification, what is their identity content, and what are their relationships? Leaders can then determine how strongly to emphasise shared and/or subgroup identities, weighing the benefits of increased unity against the risks of identity threat. Where professional identification is stronger than organisational identification, leaders need to offer greater support to physician identity (either in general or in subgroups that resonate more strongly with local physicians, e.g. specialists or particular specialties). Where organisational identification is strong, leaders can more confidently advance a common identity – while remaining aware that in complex organisations, a mosaic that incorporates subgroup identities is typically more attractive than a monolith (Haslam et al., 2003). To appeal to physicians who do not identify strongly with any group (or view individualism as a crucial element of physician identity), leaders may consider individualistic financial incentives – bearing in mind that these can undermine organisational identification (Alexander et al., 2001), and small-group – based incentives may be preferable. To mitigate potential incongruence between professional and organisational identities, leaders may promote “hybrid” identities, incorporating certain aspects of managerialism into physician identity (Hotho, 2008), or defining organisational identity as an extension of physician identity (cf. the Mayo Clinic; Berry and Seltman, 2008). The options are as diverse as organisations themselves; the key, however, is to understand social identities in order to work with and through them. There is no single path to physician engagement; planning the way forward requires a careful mapping of the social identity landscape. References Alexander, J.A., Waters, T.M., Boykin, S., Burns, L.R., Shortell, S.M., Gillies, R.R., Budetti, R.P. and Zuckerman, H.S. (2001), “Risk assumption and physician alignment with health care organizations”, Medical Care, Vol. 39 No. 7 Supplement 1, pp. 146-161. Bartels, J., Peters, O., de Jong, M., Pruyn, A. and van der Molen, M. (2010), “Horizontal and vertical communication as determinants of professional and organizational identification”, Personnel Review, Vol. 39 No. 2, pp. 210-226. Berry, L.L. and Seltman, K.D. (2008), Management Lessons from Mayo Clinic, McGraw-Hill, New York, NY. Doolin, B. (2004), “Power and resistance in the implementation of a medical management information system”, Information Systems Journal, Vol. 14 No. 4, pp. 343-362. Dukerich, J.M., Golden, B.R. and Shortell, S.M. (2002), “Beauty is in the eye of the beholder: the impact of organizational identification, identity, and image on the cooperative behaviors of physicians”, Administrative Science Quarterly, Vol. 47 No. 3, pp. 507-533. Fiol, C.M., Pratt, M.G. and O’Connor, E.J. (2009), “Managing intractable identity conflicts”, Academy of Management Review, Vol. 34 No. 1, pp. 32-55. Grimshaw, J., Eccles, M., Thomas, R., MacLennan, G., Ramsay, C., Fraser, C. and Vale, L. (2006), “Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998”, Journal of General Internal Medicine, Vol. 21, Supplement 2, pp. S14-S20.

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Haslam, S.A. (2004), Psychology in Organizations: The Social Identity Approach, 2nd ed., Sage Publications, London. Haslam, S.A., Eggins, R.A. and Reynolds, K.J. (2003), “The ASPIRe model: actualizing social and personal identity resources to enhance organizational outcomes”, Journal of Occupational and Organizational Psychology, Vol. 76 No. 1, pp. 83-113. Haslam, S.A., Reicher, S. and Platow, M.J. (2011), The New Psychology of Leadership: Identity, Influence, and Power, Psychology Press, London. Hekman, D.R., Steensma, H.K., Bigley, G.A. and Hereford, J.F. (2009), “Effects of organizational and professional identification on the relationship between administrators’ social influence and professional employees’ adoption of new work behaviour”, Journal of Applied Psychology, Vol. 94 No. 5, pp. 1325-1335. Hewett, D.G., Watson, B.M., Gallois, C., Ward, M. and Leggett, B.A. (2009), “Communication in medical records: intergroup language and patient care”, Journal of Language and Social Psychology, Vol. 28 No. 2, pp. 119-138. Hotho, S. (2008), “Professional identity – product of structure, product of choice”, Journal of Organizational Change Management, Vol. 21 No. 6, pp. 721-742. Hroscikoski, M.C., Solberg, L.I., Sperl-Hillen, J.M., Harper, P.G., McGrail, M.P. and Crabtree, B.F. (2006), “Challenges of change: a qualitative study of chronic care model implementation”, Annals of Family Medicine, Vol. 4 No. 4, pp. 317-326. Kreindler, S.A., Dowd, D.A., Star, N.D. and Gottschalk, T. (2012a), “Silos and social identity: the social identity approach as a framework for understanding and overcoming divisions in healthcare”, Milbank Quarterly, Vol. 90 No. 2, pp. 347-374. Kreindler, S.A., Larson, B.K., Wu, F.M., Carluzzo, K.L., Gbemudu, J.N., Struthers, A., Van Citters, A.D., Shortell, S.M., Nelson, E.C. and Fisher, E.S. (2012b), “Interpretations of integration in early accountable care organizations”, Milbank Quarterly, Vol. 90 No. 3, pp. 457-483. Larson, B.K., Van Citters, A.D., Kreindler, S.A., Carluzzo, K.C., Gbemudu, J.M., Wu, F.M., Shortell, S.M., Nelson, E.C. and Fisher, E.S. (2012), “Advancing accountable care: insights from the Brookings-Dartmouth ACO pilot sites”, Health Affairs, Vol. 31 No. 11, pp. 2395-2406. Levay, C. and Waks, C. (2009), “Professions and the pursuit of transparency in healthcare: two cases of soft autonomy”, Organization Studies, Vol. 30 No. 5, pp. 509-527. McCarthy, D. and Mueller, K. (2009), Organizing for Higher Performance: Case Studies Of Organized Delivery Systems, The Commonwealth Fund, New York, NY. McDonald, R., Waring, J. and Harrison, S. (2006), “Rules, safety and the narrativisation of identity: a hospital operating theatre case study”, Sociology of Health & Illness, Vol. 28 No. 2, pp. 178-202. Martin, G.P. and Learmonth, M. (2012), “A critical account of the rise and spread of ‘leadership’: the case of UK healthcare”, Social Science & Medicine, Vol. 74 No. 3, pp. 281-288. Nutting, P.A., Crabtree, B.F., Miller, W.L., Stewart, E.E., Stange, K.C. and Jae´n, C.R. (2010), “Journey to the patient-centered medical home: a qualitative analysis of the experiences of practices in the National Demonstration Project”, Annals of Family Medicine, Vol. 8, Supplement 1, pp. S45-S56. Peters, K., Haslam, S.A., Ryan, M.K. and Fonesca, M. (2013), “Working with subgroup identities to build organizational identification and support for organizational strategy: a test of the ASPIRe model”, Group and Organization Management, Vol. 38 No. 1, pp. 128-144. Randsley De Moura, G., Abrams, D., Retter, C., Gunnarsdottir, S. and Ando, K. (2009), “Identification as an organizational anchor: how identification and job satisfaction

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combine to predict turnover intention”, European Journal of Social Psychology, Vol. 39 No. 4, pp. 540-557. Reay, T. and Hinings, C. (2009), “Managing the rivalry of competing institutional logics”, Organization Studies, Vol. 30 No. 6, pp. 629-652. Sears, N. (2011), “Five strategies for physician engagement”, Healthcare Financial Management, Vol. 65 No. 1, pp. 78-82. Strauss, A. and Corbin, J. (1998), Basics of Qualitative Research: Grounded Theory Procedures and Techniques, Sage Publications, London. Taitz, J., Lee, T.H. and Sequist, T.D. (2011), “A framework for engaging physicians in quality and safety”, British Medical Journal Quality and Safety, Vol. 21 No. 9, pp. 722-728. Tajfel, H. and Turner, J.C. (1979), “An integrative theory of intergroup conflict”, in Austin, G. and Worchel, S. (Eds), The Social Psychology of Intergroup Relations, Brooks-Cole, Monterey, CA, pp. 33-47. Turner, J.C., Hogg, M.A., Oakes, P.J., Reicher, S.D. and Wetherell, M.S. (1987), Rediscovering the Social Group: A Self-Categorization Theory, Blackwell, Oxford. Author affiliations Sara A. Kreindler, Research & Evaluation, Winnipeg Regional Health Authority, Winnipeg, Canada and Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada. Bridget K. Larson, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA. Frances M. Wu, School of Public Health, University of California, Berkeley, California, USA. Josette N. Gbemudu and Kathleen L. Carluzzo, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA. Ashley Struthers, Research & Evaluation Unit, Winnipeg Regional Health Authority, Winnipeg, Canada. Aricca D. Van Citters, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA. Stephen M. Shortell, School of Public Health, University of California, Berkeley, California, USA. Eugene C. Nelson and Elliott S. Fisher, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA. About the authors Sara A. Kreindler is a Researcher with the Winnipeg Regional Health Authority and Assistant Professor in the Department of Community Health Sciences at the University of Manitoba. Her key role involves producing knowledge syntheses to help inform regional decision making, addressing such issues as healthcare silos, chronic disease, wait times, and patient engagement; she also conducts multi- and mixed-methods research and evaluation. She undertook the present study as a 2010-2011 Harkness Fellow. A Rhodes Scholar, Kreindler obtained her doctorate in Social Psychology at Oxford University. Sara A. Kreindler is the corresponding author and can be contacted at: [email protected] Bridget K. Larson is the former Director of Health Policy Implementation at the Dartmouth Institute for Health Policy and Clinical Practice. Her work focuses on advancing payment and delivery system reform to improve population health. She led the implementation and evaluation of the accountable care organisation (ACO) model through close collaboration with five national ACO pilot sites and the Brookings Institution. Previously, Larson worked at the Dana-Farber Cancer Institute on developing best practice models for a new ambulatory cancer centre. She has

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also held a variety of roles in the private sector in policy, regulatory affairs, and process development. Larson holds a Master of Science degree in Health Policy and Management from the Harvard School of Public Health. Frances M. Wu is a doctoral student in health services and policy analysis at the University of California, Berkeley, School of Public Health. Her current research interests focus on quality improvement and health information technology. Prior to pursuing her doctorate, she was a healthcare consultant in New York City and also worked in clinical and service quality improvement for a Northern California-based health system. Wu holds a Master of Science degree in Evaluative Clinical Sciences from Dartmouth College. Josette N. Gbemudu is a senior policy analyst at the National Governors Association (NGA). In this capacity, she works on issues related to healthcare system improvement, payment reform, and workforce planning and development. Prior to joining the NGA, Gbemudu was a health policy fellow at the Dartmouth Institute for Health Policy and Clinical Practice, where she focused on the implementation of payment reform models and emerging accountable care organisations. Gbemudu holds a Master’s degree in International Health Policy from the London School of Economics and Political Science. Kathleen L. Carluzzo is a health policy fellow at the Dartmouth Institute for Health Policy and Clinical Practice. She is currently pursuing a Master of Science degree in healthcare leadership from Dartmouth College. Her research is focused on population health and accountable care organisation evaluation. Previously, Carluzzo coordinated academic and community engagement in the Department of Family Medicine at Georgetown University, where she gained significant experience in academic writing; grant writing, implementation, and reporting; and qualitative research. Carluzzo holds a Bachelor of Arts degree in Political Science and in Public and Community Service Studies from Providence College. Ashley Struthers completed a Bachelor of Medical Rehabilitation in occupational therapy. After working for several years in child and adolescent mental health, she went on to attain a Master of Arts in International Development. She currently works as a Research Associate for the Winnipeg Regional Health Authority. Aricca D. Van Citters is an evaluator working with the Centre for Population Health at the Dartmouth Institute for Health Policy and Clinical Practice. She has over 12 years of experience conducting qualitative and quantitative process and outcomes evaluations in a variety of healthcare settings. Recent research projects focus on understanding the formation and performance of accountable care organisations, and understanding the factors that contribute to improvement in the quality and efficiency of care. Van Citters received a Master of Science degree in Evaluative Clinical Sciences from Dartmouth College. Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management and Professor of Organisational Behaviour at the School of Public Health and the Haas School of Business at the University of California, Berkeley. He is also Dean of the School of Public Health at Berkeley and holds appointments in the Department of Sociology at Berkeley and the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco. Shortell received his undergraduate degree from the University of Notre Dame, his Master’s degree in Public Health from the University of California, Los Angeles, and his PhD in Behavioural Sciences from the University of Chicago. During 2006-2007 he was a fellow at the Centre for Advanced Study in the Behavioural Sciences at Stanford University. A leading healthcare scholar, Shortell has received numerous awards for his research examining the performance of integrated delivery systems, the organisational factors associated with quality and outcomes of care, the development of effective hospital-physician relationships, and the factors associated with the adoption of evidence-based processes for treating patients with chronic illness. He is an elected member of the Institute of Medicine of the National Academies, past president of AcademyHealth, and past editor of Health Services Research. Eugene C. Nelson is a Professor of Community and Family Medicine at the Geisel School of Medicine at Dartmouth College and the Dartmouth Institute for Health Policy and Clinical

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Practice. He serves as the Director of Population Health and Measurement at the Dartmouth Institute and at Dartmouth-Hitchcock Health. He is a Dartmouth College graduate with training in public health and health services research (Yale University and Harvard University); his current work focuses on healthcare innovation, population health, quality improvement, and person-centred measures of health outcomes and healthcare value. Elliott S. Fisher is the James W. Squires Professor of Medicine and Community and Family Medicine at the Geisel School of Medicine and Director for Population Health and Policy at the Dartmouth Institute for Health Policy and Clinical Practice. His early research focused on exploring the causes of the twofold differences in spending observed across US regions and on understanding the implications of these variations for health and healthcare. His recent work has focused on developing policy approaches to slowing the growth of healthcare spending while improving quality. He was one of the originators of the concept of accountable care organisations and is a member of the Institute of Medicine of the National Academies.

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The rules of engagement

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1. W. Shuaib, A. M. Saeed, H. Shahid, N. Hashmi, R. Alweis, M. Ahmad, L. Rosemary Sanchez. 2015. Award incentives to improve quality care in internal medicine. Irish Journal of Medical Science (1971 -) 184, 483-486. [CrossRef] 2. Thomas Andersson. 2015. The medical leadership challenge in healthcare is an identity challenge. Leadership in Health Services 28:2, 83-99. [Abstract] [Full Text] [PDF]