Context: One of health care's foremost challenges is the achievement of integration and collaboration among the groups providing care. Yet this fundamentally group‐related issue is typically discussed in terms of interpersonal relations or operational issues, not group processes. Methods: We conducted a systematic search for literature offering a group‐based analysis and examined it through the lens of the social identity approach (SIA). Founded in the insight that group memberships form an important part of the self‐concept, the SIA encompasses five dimensions: social identity, social structure, identity content, strength of identification, and context. Findings: Our search yielded 348 reports, 114 of which cited social identity. However, SIA‐citing reports varied in both compatibility with the SIA's metatheoretical paradigm and applied relevance to health care; conversely, some non‐SIA‐citers offered SIA‐congruent analyses. We analyzed the various combinations and interpretations of the five SIA dimensions, identifying ten major conceptual currents. Examining these in the light of the SIA yielded a cohesive, multifaceted picture of (inter)group relations in health care. Conclusions: The SIA offers a coherent framework for integrating a diverse, far‐flung literature on health care groups. Further research should take advantage of the full depth and complexity of the approach, remain sensitive to the unique features of the health care context, and devote particular attention to identity mobilization and context change as key drivers of system transformation. Our article concludes with a set of “guiding questions” to help health care leaders recognize the group dimension of organizational problems, identify mechanisms for change, and move forward by working with and through social identities, not against them.

The implementation of accountable care organizations (ACOs), a new health care payment and delivery model designed to improve care and lower costs, is proceeding rapidly. We build on our experience tracking early ACOs to identify the major factors-such as contract characteristics; structure, capabilities, and activities; and local contextthat would be likely to influence ACO formation, implementation, and performance. We then propose how an ACO evaluation program could be structured to guide policy makers and payers in improving the design of ACO contracts, while providing insights for providers on approaches to care transformation that are most likely to be successful in different contexts. We also propose key activities to support evaluation of ACOs in the near term, including tracking their formation, developing a set of performance measures across all ACOs and payers, aggregating those performance data, conducting qualitative and quantitative research, and coordinating different evaluation activities.T he implementation of accountable care organizations (ACOs), a new payment and delivery model designed to improve health care and lower costs, is proceeding rapidly in both the public and private sectors. As of August 2012 we had identified 227 provider organizations that have established ACO contracts with Medicare, Medicaid, private payers, or some combination thereof.The ACO concept originated in response to a growing recognition that fee-for-service payment was a major contributor to the rapidly rising costs and poorly coordinated care that characterize the US health care system. 1 Under this new payment model, provider groups willing to be accountable for the overall costs and quality of care for their patients are eligible for a share of the savings achieved by improving care.Proponents believe that ACOs will encourage providers across the full range of practice settings-from individual office-based practices to integrated delivery systems-to improve quality and slow spending growth. Under this model, payers establish quality benchmarks and riskadjusted spending targets for the patients cared for by the physicians in the ACO. If the organization meets the quality benchmarks, it is then eligible for a share of the savings achieved below the set spending target. In some models, the organization is also at risk for a portion of any spending that exceeds the target. Early evidence on ACO performance is promising. [2][3][4] Challenges to the success of the model remain, however. Little is known about what capabilities and activities are most important to the longterm success of these new organizations. Also, the optimal design of accountable care contracts between providers and payers is uncertain.In addition, many stakeholders are concerned about the complex interactions among public and private reform initiatives based on ACOs. For example, some economists wonder whether implementation of ACOs in the Medicare popu- lation will lead to provider consolidation and thus higher prices for private payers...

This synthesis seeks to assess and explain the effectiveness of policy interventions to reduce elective wait times or lists. PubMed, EMBASE, EconLit, and grey literature were systematically searched for relevant studies and reviews. Strategies with the strongest evidence base include paying for activity, buying capacity locally and setting targets with strong incentives. There is also evidence for improving the use of existing capacity. Limiting demand through rationing can reduce waits, but is ethically problematic. Short-term injections of funding, cross-border treatment schemes, unenforced targets and promotion of private health insurance had the weakest evidence. Available evidence favours options that act fairly directly on supply, demand or local organizations' behaviour, over indirect strategies that depend on a 'domino effect'. Further research is needed to determine how to achieve major, system-wide improvements in the use of capacity.

The study of right-wing authoritarianism (RWA) and Social Dominance Orientation (SDO) as predictors of prejudice has represented an attempt to explain group dynamics in terms of individual traits. In contrast, I argue that the individual tendencies that predict prejudice are actually a product of group dynamics. This article critiques personality approaches, focusing primarily on authoritarianism and secondarily on social dominance, and defends a model that explains the 2 variables in terms of discrete group processes. According to the Dual Group Processes model, SDO reflects category differentiation, which involves the evaluation of individuals on the basis of their category membership. RWA reflects normative differentiation, which involves the evaluation of ingroup members on the basis of their prototypicality. Authoritarian aggression—whether against ethnic minorities or other targets—is conceptualized as an intragroup phenomenon, involving the rejection of perceived antinorm deviants who threaten the longevity or legitimacy of social norms.

BackgroundThe majority of internet-based anxiety and depression intervention studies have targeted adults. An increasing number of studies of children, youth, and young adults have been conducted, but the evidence on effectiveness has not been synthesized. The objective of this research is to systematically review the most recent findings in this area and calculate overall (pooled) effect estimates of internet-based anxiety and/or depression interventions.MethodsWe searched five literature databases (PubMed, EMBASE, CINAHL, PsychInfo, and Google Scholar) for studies published between January 1990 and December 2012. We included studies evaluating the effectiveness of internet-based interventions for children, youth, and young adults (age <25 years) with anxiety and/or depression and their parents. Two reviewers independently assessed the risk of bias regarding selection bias, allocation bias, confounding bias, blinding, data collection, and withdrawals/dropouts. We included studies rated as high or moderate quality according to the risk of bias assessment. We conducted meta-analyses using the random effects model. We calculated standardized mean difference and its 95% confidence interval (95% CI) for anxiety and depression symptom severity scores by comparing internet-based intervention vs. waitlist control and internet-based intervention vs. face-to-face intervention. We also calculated pooled remission rate ratio and 95% CI.ResultsWe included seven studies involving 569 participants aged between 7 and 25 years. Meta-analysis suggested that, compared to waitlist control, internet-based interventions were able to reduce anxiety symptom severity (standardized mean difference and 95% CI = −0.52 [−0.90, −0.14]) and increase remission rate (pooled remission rate ratio and 95% CI =3.63 [1.59, 8.27]). The effect in reducing depression symptom severity was not statistically significant (standardized mean difference and 95% CI = −0.16 [−0.44, 0.12]). We found no statistical difference in anxiety or depression symptoms between internet-based intervention and face-to-face intervention (or usual care).ConclusionsThe present analysis indicated that internet-based interventions were effective in reducing anxiety symptoms and increasing remission rate, but not effective in reducing depression symptom severity. Due to the small number of higher quality studies, more attention to this area of research is encouraged.Trial registrationPROSPERO registration: CRD42012002100

BackgroundHealth systems in many jurisdictions struggle to reduce Emergency Department congestion and improve patient flow across the continuum of care. Flow is often described as a systemic issue requiring a “system approach”; however, the implications of this idea remain poorly understood. Focusing on a Canadian regional health system whose flow problems have been particularly intractable, this study sought to determine what system-level flaws impede healthcare organizations from improving flow.MethodsThis study drew primarily on qualitative data from in-depth interviews with 62 senior, middle and departmental managers representing the Region, its programs and sites; quantitative analysis of key flow indicators (1999–2012) and review of ~700 documents furnished important context. Examination of the interview data revealed that the most striking feature of the dataset was contradiction; accordingly, a technique of dialectical analysis was developed to examine observed contradictions at successively deeper levels.ResultsAnalysis uncovered three paradoxes: “Many Small Successes and One Big Failure” (initiatives improve parts of the system but fail to fix underlying system constraints); “Your Innovation Is My Aggravation” (local innovation clashes with regional integration); and most critically, “Your Order Is My Chaos” (rules that improve service organization for my patients create obstacles for yours). This last emerges when some entities (sites/hospitals) define their patients in terms of their location in the system, while others (regional programs) define them in terms of their needs/characteristics. As accountability for improving flow was distributed among groups that thus variously defined their patients, local efforts achieved little for the overall system, and often clashed with each other. These paradoxes are indicative of a fundamental antagonism between the system’s parts and the whole.ConclusionAn accretion of flow initiatives in all parts of the system will never add up to a system approach, and may indeed perpetuate the paradoxes. What is needed is a coherent strategy of defining patient populations by needs, analyzing their entire trajectories of care, and developing consistent processes to better meet those needs.

Despite a sizeable body of literature, the available information is insufficiently precise to inform clinical or service-planning decisions; there is a need for a predictive model, including specific patient complaints. Deeper understanding of the determinants of ED LOS could help to identify patients and/or populations who require special intervention or resources to prevent a protracted stay.

Context:It is widely hoped that accountable care organizations (ACOs) will improve health care quality and reduce costs by fostering integration among diverse provider groups. But how do implementers actually envision integration, and what will integration mean in terms of managing the many social identities that ACOs bring together?Methods: Using the lens of the social identity approach, this qualitative study examined how four nascent ACOs engaged with the concept of integration. During multiday site visits, we conducted interviews (114 managers and physicians), observations, and document reviews. Findings:In no case was the ACO interpreted as a new, overarching entity uniting disparate groups; rather, each site offered a unique interpretation that flowed from its existing strategies for social-identity management: An independent practice association preserved members' cherished value of autonomy by emphasizing coordination, not "integration"; a medical group promoted integration within its employed core, but not with affiliates; a hospital, engaging community physicians who mistrusted integrated systems, reimagined integration as an equal partnership; an integrated delivery system advanced its careful journey towards intergroup consensus by presenting the ACO as a cultural, not structural, change.