The discoveries of basic scientific and clinical research have no impact on patients' health unless they are used effectively by the health care delivery system. During the past two decades, there has been a good deal of research focused on the U.S. health care delivery system; this research has been funded almost entirely by AHRQ and foundations. This paper presents a simple conceptual model for thinking about the delivery system in terms of individual organizations or of relations among organizations. The paper argues that research has been heavily focused on intraorganizational processes; these are important, but not enough attention has been paid to interorganizational processes and to other components of the model—structure, culture/leadership, and incentives. These other components strongly influence the processes that are used and how effective these processes are. Most of AHRQ's recent ARRA grants for comparative effectiveness research include attention to these other components, though for the most part the focus remains on processes.
Although a method rather than an area of research, "formative evaluation" will be very important in the types of research advocated in this paper.35 A formative evaluation component should be an important part of many—probably most—research projects. To evaluate the findings of a project and to draw practical lessons from it, it will be critical for policymakers and leaders of provider organizations to learn what was actually done, what barriers arose, what were ways of overcoming these barriers, how did participants think that the program being evaluated could be improved, etc. This means that researchers should be prepared to use (and funders to fund) mixed methods: quantitative analysis of primary and/or secondary data sources as well as interviews and surveys.
