How Stakeholder Perceptions of Quality Shape Healthcare Transactions: Insights from Key Decision-Makers Across the Ecosystem

Abstract

Goal:

In today’s healthcare ecosystem, quality measures are theorized to inform the spectrum of healthcare delivery and evaluation, including specific functional areas such as quality improvement, regulation, accreditation, and value-based payment. Yet, the ways in which expectations about quality—real or perceived—shape and inform transactional relationships between healthcare stakeholders have not been well elucidated. We elicited the perspectives of healthcare decision-makers to understand their experiences with quality and how they may influence transactions and strategic alliances.

Methods:

A qualitative study incorporating semistructured in-depth interviews conducted with C-suite and D-suite decision-makers in the United States representing a mix of different types of healthcare organizations. Interviewees were asked about organizational culture and strategic priorities, qualities sought in potential business partners, and factors that drive decisions to transact with external partners. Interviews were audio-recorded and transcribed verbatim, and data were analyzed to identify key themes.

Principal Findings:

Quality, as an objective measure (e.g., the Healthcare Effectiveness Data and Information Set [HEDIS] or the Consumer Assessment of Healthcare Providers and Systems [CAHPS]), or a subjective assessment, was only one of many considerations that shaped transactional relationships with external healthcare stakeholders. Key informants described a range of factors considered, including partner reputation, alignment of culture and mission, and ability to achieve strategic priorities. While the term quality was broadly used and defined among the key informants, participants often incorporated the term value into their lexicography of quality and felt that value played a more significant role in decision-making. Standardized quality measures can be useful both for prompting investment within organizations and for deciding when to seek the assistance of external parties to help improve commonly collected and reported quality measures. Ultimately, the manner in which quality manifests in real-world practice and operations is not as simple or straightforward as policymakers or quality metrics developers may believe.

Practical Applications:

Although there has been significant public and private investment in quality initiatives, including their use in payment and regulatory models, this study elucidates how stakeholders across the healthcare ecosystem assess quality from a strategic operating perspective. We identified a number of key drivers that underpin transactional relationships and that ultimately impact the results of standardized and publicly reported quality measures captured for payment, regulation, and public accountability purposes. While decisions regarding these relationships are internal matters and thus fall outside the scope of regulators, policymakers and regulators need to understand their importance and likely correlation with what is ultimately measured and used for payment, regulation, and public transparency.

INTRODUCTION

More than two decades ago, the Institute of Medicine’s (2001) seminal report, Crossing the Quality Chasm, highlighted many failures of the U.S. healthcare system and served as a call to action to improve systemic issues pertaining to healthcare quality (Dentzer, 2011). While quality has always been important to healthcare stakeholders (Donabedian, 1966), the report cemented its pivotal role and has only grown in importance as a central tenet of healthcare delivery in the United States. Quality is often assessed in terms of structural, process, or outcome measures (Rademakers et al., 2011). Such measures are used by certain stakeholders, such as commercial payers and provider systems, to promote value, and at times, to control expenditures through payment models or public transparency and accountability efforts (Saver et al., 2015). Yet, despite recommendations to achieve continuous improvement in care and develop standards for collecting, analyzing, and reporting quality-of-care outcomes data, the U.S. healthcare system is still not operating in a way that adequately measures or rewards value (Shortell et al., 2023).

Traditional definitions of quality may fail to capture the specific factors that represent quality across stakeholder relationships and how these factors may change over the life cycle of those relationships. Today, healthcare organizations are structured through a series of transactional relationships across and between stakeholders and organizations (ISPOR, 2020). These relationships, including decisions to enter into, continue, and end transactions between organizations, directly influence the myriad ways in which quality initiatives are implemented, evaluated, and achieved throughout the healthcare ecosystem. The current U.S. healthcare ecosystem is unique in that it is heavily regulated by government entities, but also highly capitalistic.

Understanding how stakeholders assess and transact based on quality is necessary to appreciate how they work together (or not) to deliver healthcare in the United States. These relationships are predicated on several factors, including operational, financial, and quality-related considerations. Although much has been more broadly reported on quality impacts, how stakeholder-specific definitions or concepts of quality influence and mediate the initiation, continuation, or termination of cross-stakeholder relationships and transactions is less well understood. Further, explicit elements of quality (e.g., outcome measures, patient satisfaction, cost of care) have been well elucidated, while implicit concepts and definitions (e.g., reputation, specific capabilities, previous experience working together) have not been well articulated (Ehlers et al., 2017; Wray et al., 2021). This study aimed to investigate how expectations about quality, whether real or perceived, influence transactional relationships between healthcare stakeholders. We systematically elicited the perspectives of key healthcare decision-makers to understand their experiences with transactional relationships and strategic alliances, their definitions of quality, and the role of quality and quality considerations over the course of those relationships.

Conceptual Framework

The healthcare ecosystem comprises multiple interconnected entities, each involved in various forms of transactional relationships associated with the financing and delivery of healthcare. We sought to identify how the concept of quality is conceived by key decision-makers when interacting with other stakeholders in the healthcare ecosystem. We conducted a targeted literature review during framework development to capture conceptions of quality, outline the spectrum of quality elements within these transactional relationships, and identify topics to be explored during qualitative data collection. While the targeted literature review was not exhaustive, we were able to extract information on key stakeholders involved in quality initiatives and establish a baseline assessment of how quality has been defined by these stakeholders.

Figure 1 outlines the healthcare ecosystem quality pathway and describes potential dyadic relationships with interdependent measures that could signify quality. For example, in examining the dyadic relationships between a payer and a pharmacy benefits manager (PBM), we hypothesized that the terms of the service contract and adherence to or exceeding expectations on the contract in delivery of services could constitute interdependent measures. While any attempt at describing the complex healthcare system will be overly simplified, the aim of Figure 1 is to illustrate patient interactions in the care delivery pathway (e.g., between patients and providers working for integrated delivery networks [IDNs] or hospitals), demonstrate the complexity of U.S. healthcare by incorporating the ways in which care is financed e.g., identifying the role of PBMs, and illustrate the role of third-party payers (e.g., Medicare, Medicaid, commercial insurers) in establishing pricing and payment for medical care services. The bulleted items represent our hypothetical thinking regarding how theoretical traits of quality are valued by the relevant stakeholders, which we sought to explore using key informant interviews.

FIGURE 1.

The Healthcare Ecosystem Quality Pathway: Dyadic Relationships with Interdependent Measures Connotating “Quality”

Note. IDNs = integrated delivery networks; MDO = medical doctor’s office; PBM = pharmacy benefits manager; PRO = patient-reported outcomes; P4P = pay for performance.

Transactions between stakeholders in the healthcare ecosystem typically follow a processual framework, in that there is a distinct beginning, middle (or maintenance period), and end (Ring & Van de Ven, 1994). This study explored how factors (e.g., business need) across the life cycle, with a specific focus on the role of quality, impact decisions throughout the relationship. The first phase is the decision to transact with an external stakeholder (Initiation). The next phase involves decisions regarding strategies and processes for monitoring and maintaining the relationship (Continuation). The third phase involves the decision to potentially end a transactional relationship (Termination). Moving forward, we refer to these three phases of the interorganizational relationship life cycle as ICT.

In developing our conceptual framework, we were particularly interested in understanding the sphere of control in decision-making, motivations for engaging in transactional relationships, and how an individual participant’s department and/or role within their organization mediated decision-making. Our primary objective was to investigate what each stakeholder sought to gain from transactional relationships, the level of goal alignment, and definitions of mutual benefits accorded to the partnership. We also sought to better understand if and how quality matters among stakeholders, and if and how the importance of quality varies throughout the relationships.

METHODS

Study Design

To understand perceptions of quality among senior and mid-level healthcare decision-makers and how such perspectives influence strategic alliances in the healthcare ecosystem, we conducted a qualitative study incorporating semi-structured in-depth interviews. Participants provided case examples to illustrate how expectations about quality influence the relationships between stakeholders. Qualitative data are reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong et al., 2007). The Advarra Institutional Review Board (Columbia, Maryland) reviewed the study procedures and deemed the study exempt from full review.

Study Sample

The study included participants from five specific stakeholder groups of interest in the Care Delivery Pathway (see Figure 1). These included (1) IDNs/hospital systems, (2) payers, (3) physicians/providers, (4) PBMs, and (5) pharmacy organizations, as well as one group of (6) “other” stakeholders. We selected these groups because of their frequent interactions, as well as to achieve a holistic understanding of how quality is perceived and impacts decisions related to transactional relationships.

We used a purposive sampling strategy to recruit individuals based on their professional role within the specified stakeholder group. Recruitment was supplemented by snowball sampling, in which participants offered to refer individuals with relevant professional histories. The sampling drew upon a panel of current and former US medical, pharmacy, and payer experts maintained by Precision AQ (formerly Precision Value & Health), a healthcare consultancy group. The panel administrator emailed prospective participants currently in or previously holding C- and D-suite roles at organizations representing the six stakeholder groups of interest. Participants in these positions were most likely to be sponsors of, and/or involved in setting strategic organizational priorities where quality may factor into decisions to engage with external entities. The invitation included a link to a web-based screening questionnaire to assess study eligibility. We aimed to include participants with a mix of individual characteristics, diversity of relationships, and different levels of decision-making authority. The study was double-blinded in that participants were not informed of the sponsor of the study, and the sponsor was not informed of the identity of any participants. In addition, the Precision AQ panel administrator coordinated all invitations and interview scheduling, with the research team informed only of the interviewee’s role and affiliated organization. All participants who completed a web-based or telephone interview were provided an honorarium by the panel administrator to compensate for their time. Although the study was sponsored by a life sciences company, there was no link to any products or services, eliminating concern that the commercial interests of the study sponsor might bias recruitment or participant opinions. The findings reported here are solely those of the authors.

Data Collection

A semistructured interview guide was developed to inquire about (1) organizational culture and strategic priorities, (2) qualities sought in potential business partners, and (3) factors that drove decisions to transact with external partners, including mechanisms to monitor the partners’ performance (see Table 1).

TABLE 1.

Interview Discussion Guide Domains and Sample Questions

Domain	Objectives	Discussion Guide Sample Questions
Relationships with external stakeholders	To understand priorities around engaging with external stakeholders, as well as identify the types of transactional relationships the participant is engaged in	What types of organizations outside of your own do you assess for potential partnerships or contracting, or contribute to decision-making about entering into a formal contractual relationship? What do you look for when deciding to engage with external stakeholders?
Factors that impact ICT	To identify factors related to engagement with other individuals with respect to the initiation, continuation, and termination of external relationships; have participants identify the factors and characteristics that determine and mediate such relationships	What motivated you to engage with [organization/individual]? What factors were considered as part of the decision-making process? How do you formally and informally assess whether the relationship with [organization] is worthwhile to continue? What, if anything, would lead your organization to consider terminating a relationship with an organization?
Perspectives on the role of quality in ICT	To explore conceptions of the term “quality” and other ways to describe it, considering relationships and factors discussed	In what other ways, if any, do you assess quality in current or potential partnerships? What does the term “quality” bring to mind within your particular organizational context?
COVID-19 pandemic impacts	To elicit perspectives on the impacts of the COVID-19 pandemic on transactional relationships	How do you think the COVID-19 pandemic has impacted or will impact how your organization makes decisions about external relationships?

Note. ICT = initiation, continuation, and termination of external relationships.

Team members with graduate training in qualitative research conducted web-based interviews between December 2020 and December 2021. Interviews were audio-recorded with the participant’s permission. Interviewers were blinded to participants’ identities but were aware of participants’ specific roles and organizations. As such, participants were asked to provide general background and contextual information about themselves and their organization.

We explored participants’ or their organization’s motivation to pursue a transactional relationship with an external stakeholder, the factors considered as part of the decision-making process, any work leading up to the decision, and the participant’s role in initiating the relationship. We also asked participants how they or their organization formally or informally assessed the health of a transactional relationship by eliciting specific examples of when, why, how, and how frequently transactional relationships were formally evaluated, and descriptions of the participant’s role in evaluating the relationship. Lastly, we asked how formal or informal assessments mediated decisions to terminate a relationship or reconsider other vendor partners. Who was responsible for terminating the relationship? What factors were considered in the decision? What processes and decision-making led up to the termination?

During the first part of the interview, interviewers deliberately did not inquire about or invoke the term “quality” to facilitate an unbiased narrative on this topic. In the second half of the interview, participants were explicitly asked about quality—how they defined it, and how quality factored into the case studies they shared and, if at all, into their decision-making processes. Although the lines of inquiry were broad, we sought to map decisions about relationships to conceptions of quality throughout the relationship life cycle.

Data Analysis

Interviews were transcribed verbatim and imported into Dedoose (Version 9.0.17, 2021) to facilitate qualitative coding and data analysis. We used a grounded theory approach to identify the drivers of ICT with respect to the case examples described (Glaser & Strauss, 1967). First, three team members independently developed in vivo codes to classify participants’ descriptions of the relationships and the components, e.g., potential drivers of quality, such as “service,” “trust,” and “financial considerations,” inherent in the case study examples. These codes informed the development of a coding dictionary used to categorize the range of experiences and opinions shared in the interviews. The team reached consensus on the initial coding structure with 15 thematic codes. Next, researchers applied the codes to all interview data to identify drivers of the relationship stages and definitions of quality explicitly stated or implicitly discussed during the interviews. Table 2 summarizes the 12 driver codes associated with overarching concepts that interact with or mediate quality. Lastly, we conducted a thematic analysis to identify overarching themes and key concepts across interviews, as well as to assess patterns and degree of concordance and/or divergence between and within stakeholders across topics. Relationships between codes were mapped and the coded segments were synthesized to place the interview findings in context. Illustrative quotes are included to highlight the findings.

TABLE 2.

Drivers That Influence the Initiation, Continuation, and Termination of External Relationships

Driver	Definition
Access	Participant considers increasing market share and/or expanding their organization’s access when assessing relationships with external stakeholders.
Alignment	Participant considers the alignment of key organizational attributes such as culture, ethos, mission, vision, values, strategies, and goals, when assessing relationships with external stakeholders.
Familiarity	Participant considers their familiarity (or their organization’s familiarity) with an external stakeholder when assessing relationships.
Financial considerations	Participant considers financial factors, including efforts to manage costs, when assessing relationships with external stakeholders.
Information technology	Participant considers information technology and data security when assessing relationships with external stakeholders.
Innovation	Participant considers an organization’s efforts to be innovative, if/how it collaborates with others to be innovative, and/or if/how it looks to others to drive innovation when assessing relationships with external stakeholders.
Legal	Participant considers regulations, regulatory considerations, and/or legal considerations when assessing relationships with external stakeholders.
Population management	Participant considers population management, including care coordination and disease management, when assessing relationships with external stakeholders.
Quality	Participant considers quality factors, both clinical and nonclinical, when assessing relationships with external stakeholders.
Reputation	Participant considers an organization’s reputation when assessing relationships with external stakeholders.
Service	Participant considers service and satisfaction when assessing relationships with external stakeholders.
Trust	Participant considers trust when assessing relationships with external stakeholders.

RESULTS

Participants

Of the 370 potential participants who responded to the study invitation, 139 (37.6%) met the eligibility criteria. Potential participants were excluded if they did not provide consent, refused to participate in a web-based or telephone interview, or were not involved in a decision-making role within a stakeholder group of interest. Interviews were conducted with 81 participants representing the six stakeholder groups: IDNs/hospital systems (n = 21), payers (n = 20), physician/provider groups (n = 18), PBMs (n = 10), pharmacy organizations (n = 8), and a group classified as “other” (n = 4). Of these 81 individuals, 30 (37%) held C-suite positions and 51 (63%) held D-suite roles. A separate, optional demographic survey was completed by 58 participants (71.6%). Approximately half of these participants (n = 28; 48.3%) reported a tenure of more than 10 years in their current position, followed by 41.4% (n = 24) who had been in their current position for three to 10 years, and 10.3% (n = 6) who had been in their current position for two years or less.

Qualitative Findings

Results of the qualitative analysis centered around two categories: (1) the role of quality in transactional relationships throughout the healthcare ecosystem (i.e., When stakeholders talk about quality, what do they mean, or how does this concept present itself?), and (2) the role of the 12 identified drivers throughout the life cycle of these relationships (i.e., What drives or instigates these relationships, and how does the concept of quality play a role?).

The Role of Quality in Transactional Relationships

We found that quality can be viewed as an essential aspect of value in the healthcare setting, as well as a more pervasive barometer or bellwether of the status of relationships. Specifically, stakeholders viewed quality as an intrinsic element of value assessment in healthcare. Quality and value appear to be linked and frequently are described in mathematical terms (e.g., as components of a formula or an equation). Many viewed the relationship between quality and value through the lens of the value formula or equation, which tempers quality with the related financial investment. One stakeholder described the value formula as “Quality divided by cost. If the denominator is too high, which is the cost, then there is no value to us. You may have high quality and high cost, and then the value is zero.”

The impetus to measure quality (e.g., for payment, assessment, transparency, licensing and accreditation, improvement) also serves as the incentive to evaluate the perceived health (i.e., robustness and stability) of these relationships; it is demonstrated through ensuring reputations, maintaining trust, and delivering service that informs quality metrics. The presence, absence, and degree of quality displayed in these subcategories serve as a barometer of the health of the relationship with the external stakeholder. One payer described this as follows:

There is another piece here, which is trust and comfort level, alignment—that cultural comfort with the organization which is also important. I think, on the nonfinancial side, one could consider quality but also the caliber of the relationship. I gave you a particularly egregious example (of an event that led to a breakdown in trust), but it happens. If it happens at that level, it almost doesn’t matter how good the other pieces are, because we’re not going to listen or trust them.

While reputation, trust, and service are vital components of quality throughout the relationship, particular weight is placed on reputation at the initiation of the relationship, with trust established early on and developing (or not) over time. A partner’s reputation paves the way to building trust. As with trust, quality in the form of service delivery is detected early on and assessed throughout the relationship. As described by a provider stakeholder, “I think the reputation of the organization is very important. In my mind, reputation is developed over a period of time where there’s been demonstrable high-quality patient care delivered.” Issues with or the absence of any of these components can lead to the termination of the relationship.

Drivers of Quality in Transactional Relationships

We identified a number of drivers that impact the concepts of quality and ultimately affect satisfaction in transactions between stakeholder groups. Our analysis revealed several overarching themes at each stage (i.e., ICT) of the relationship: (1) quality, (2) perceived value, and (3) individual organizational goals or strategies. Drivers were identified and defined through both explicit and implicit data collected through the interviews, and can be roughly separated into two categories. The first category includes drivers that address specific business needs (e.g., financial considerations, information technology, innovation, legal considerations, population management). The second category includes drivers that signal positive, prosocial behaviors typified in a strong relationship (e.g., alignment, familiarity, quality, reputation, service, trust, and access). While the frequency of the 12 drivers within each stakeholder group varied, nearly all drivers were reported across the various stakeholder interviews (see Figure 2). Perhaps owing to the fact that these were transactional business relationships, financial considerations, service, and quality figure prominently as drivers across all stakeholder groups.

FIGURE 2.

Drivers of ICT by Stakeholder Group

Note. ICT = initiation, continuation, and termination of external relationships (see Table 2 for ICT driver definitions).

Initiation Phase

The analyses revealed that the reasons for seeking relationships in the Initiation phase were complex and varied. At the crux of every new relationship, regardless of stakeholder group, was a desire to further strategic organizational goals. More often than not, these relationships are governed by requests for proposals, reimbursement rates, procurement guidelines, mandates from the Centers for Medicare & Medicaid Services, National Committee for Quality Assurance accreditation status, and myriad other decisional controls. Thus, many interviews centered on these requisite aspects of these relationships. However, participants from stakeholder groups directly involved in delivering patient care (i.e., physician/provider groups, hospital systems/IDNs, and pharmacy organizations) also described seeking quality relationships with external stakeholders that supported or improved patient care, filled a gap in service delivery, or were in alignment with the organization’s care delivery mission. Drivers of initiation for these stakeholders were more focused on the positive, prosocial category and included service, financial considerations, quality as perceived by the participant (i.e., explicit statements about quality as a factor in the given transactional relationship), reputation, trust, familiarity, alignment, and legal issues. As one provider described:

I like to say I’m getting old in this business, but the good news is, I’ve never really lost sight of what I’m here to do and that’s to take great care of cancer patients. I suppose if I ever lose that, I should retire. At the forefront of that relationship was making sure [it] was going to provide better care to people fighting cancer. Step 1 was, are you able to build a seamless process for us to get patients to you so they don’t feel like they’re jumping through 100 hoops to get care that we can’t provide locally?

In contrast, stakeholders from the payer and PBM groups primarily focused on meeting business needs, generating profit, and innovating to ensure relevance in the market. Payer participants prioritized relationships that increased return on investment (ROI) while ensuring minimal disruption to plan members. For example, one payer stakeholder stated, “It’s price. It’s scale. Yeah. It’s usually the biggest company with the best price. You can’t be in the health plan business and not know that the bottom line—it’s always going to be price.” For payer participants, specific drivers commonly included service, financial considerations, perceptions of quality by the participant, legal considerations, innovation, information technology, population management, and access. PBM participants prioritized the need to maintain positive relationships with partners, and often cited service, financial considerations, quality, legal issues, and innovation as drivers.

Continuation Phase

At the Continuation phase, the decision to continue a relationship is primarily based on the external stakeholder’s effectiveness in meeting specific business needs, usually outlined at the beginning of the contractual relationship. Participants noted that entering into a transactional relationship with a new partner can be a lengthy, complicated, and burdensome process requiring significant time and investment. Thus, many stated that they preferred the path of least resistance and continued with the relationship unless there was clear reason or an incentive to make a change. Across all stakeholder groups, participants described relying on formal quality assessments at regular intervals and monitoring performance metrics as a means to support the continuation of a relationship. These metrics and assessments were commonly built into contractual agreements.

Termination Phase

In the final phase, Termination, the decision to end a business relationship was primarily based on an external partner’s real or perceived inability to continue meeting the business needs outlined at the outset. Several participants noted that relationships came to a natural end on completion of the contracted services, or organizational priorities changed, and while the relationship served its intended purpose, there was no need to continue it. On rare occasions, terminations occurred in response to safety issues or extremely poor performance. Participants expressed a strong aversion to premature and unexpected termination of partnerships. Terminations were considered complex, difficult, and best avoided because of the significant investment in establishing the relationship. In addition, key decision-makers need to carefully consider the impact on patients or customers before ending a contract. To the degree possible, most stakeholders expressed a desire to terminate amicably, given that reputations and other relationships may be jeopardized. One PBM stakeholder described the situation as:

It’s never in the best interest [of the organization to anger somebody], so you’re always best off trying to form and maintain relationships. You build them, you create a new relationship, and you try to continue to build and maintain that relationship. Even if it’s going to terminate, you try to terminate amicably because you never know when that client might want to come back, that broker might decide they want to put more business with you, that competing PBM needs your help or is willing to assist you in another way. So, you never try to terminate a relationship.

DISCUSSION

In this study, we sought to describe how perceptions of quality manifest in transactional relationships among key decision-makers in the U.S. healthcare ecosystem. The study findings highlight the extent to which decision-makers in healthcare organizations think holistically about transactional relationships and with whom they choose to partner to achieve strategic priorities and ensure organizational performance. Specifically, quality as a construct has multiple dimensions across the life cycle of a transactional relationship. Further, the results of this study show that while significant attention has historically been given to the role of standardized quality performance measures, in real-world practice, these measures are only one among many considerations that mediate transactional relationships between healthcare stakeholders.

Although formal quality measures like the Healthcare Effectiveness Data and Information Set (HEDIS), the Consumer Assessment of Healthcare Providers and Systems (CAHPS), and others are used to evaluate organizations and their quality, our study findings suggest that many factors influence quality in healthcare and therefore are critical to ensuring appropriate incentives (e.g., from a policy and payment perspective) (Shortell et al., 2023). When healthcare decision-makers brings on partners, it is not the HEDIS/CAHPS-like measures that matter, but drivers such as trust, value, reputation, and ROI. Entities that choose to transact with each other are only looking at quality within the context of their own interests, subject to regulations. The focus in the United States has been on the development of formal quality measures; however, participants reported that while these may be important, there are other important practical dimensions of quality that trump formal quality measures. Thus, formal quality measures serve an evaluative purpose, while quality with respect to healthcare services or business production serves a more strategic purpose. Formal quality measures will not disappear, nor should they. However, questions remain as to whether the drivers of quality for strategic purposes translate directly to better or worse publicly facing quality measures and the implications this holds for practice or payment models.

Our study has shed light on an “alternative quality world” that has not been well articulated or appreciated because of the emphasis on publicly and formally reported organizational quality measures. Yet, the business of providing healthcare involves myriad transactional relationships, and key decision-makers view quality in a thoughtful and sophisticated way. This study sought to focus on these elements of quality rather than the publicly reported quality measures, although they certainly are important to organizations. Interestingly, although we interviewed participants representing C- and D-suite positions, we did not find much distinction between the two roles, likely because decision-makers described specific transactional relationships. That said, C-suite participants tended to describe organizational objectives and strategic priorities more broadly, whereas D-suite participants focused on the operational or strategic priorities of their respective division or department.

Study Limitations

This study has several limitations. The findings represent the views of a convenience sample of healthcare decision-makers representing specific stakeholder groups who were interviewed during a global pandemic. A key perspective not captured in this study is that of the patient. Although this perspective is important, it was not the central focus of this study on formal transactional relationships. We collected data using qualitative interviews, and as with any qualitative study, statistical generalizability or the identification of causal pathways is not the goal. Further validation of views expressed is warranted, potentially by means of larger-scale surveys or other available secondary transactional data.

Participants in this study described a range of considerations that shaped decisions to transact with external stakeholders, including the external organization’s reputation, seeming alignment on culture and mission, potential ROI, and the ability of the other party to help the participant’s organization achieve strategic priorities or fill a gap or service need. Our study also highlights a critical need for methodologically sound and relevant research and best practices beyond quality metrics to objectively evaluate the health of transactional relationships between stakeholders in the healthcare ecosystem, particularly if they directly impact patient care and outcomes. We acknowledge that challenges remain in holistically addressing quality in a continually evolving and dynamic ecosystem. However, this study provides insights based on participant experiences, and suggests areas in which to pursue research on value and quality, among other drivers of decision-making. Further research is warranted to systematically examine and quantify the extent to which these perspectives and experiences exist in the healthcare ecosystem among a larger sample of decision-makers.

CONCLUSION

Quality was only one of many considerations that shaped transactional relationships with external healthcare stakeholders. While the term “quality” was broadly used and defined, participants often incorporated the term “value” into their vocabulary of quality and felt that value played a more significant role in decision-making. Ultimately, the manner in which quality manifests in real-world practice and operations is not as simple or straightforward as policymakers or quality metrics developers may believe.