Hospital & health services administration最新文献

An integrated delivery system (IDS) in healthcare must coordinate patient care across multiple functions, activities, and operating units. To achieve this clinical integration, senior management confronts many challenges. This paper uses a cross-functional-process (CFP) framework to discuss these challenges. There are ten CFPs that fall into three categories: planning processes (strategy formulation, program adaptation, budget formulation), organizational processes (authority and influence, client management, conflict resolution, motivation, and cultural maintenance), and measurement and reporting processes (financial and programmatic). Each process typically spans several functional units. Senior management must consider how to improve both the functioning of each CFP, as well as its "fit" with the other nine. The result can be greater clinical integration, improved cost management, and more coordinated care for enrollees.

Our Lady of the Way Hospital, like most hospitals in the late 1980s and early 1990s, exemplified the bureaucratic organization represented by the traditional "line and box organization chart." Additionally, as in most small hospitals, the CEO of Our Lady of the Way Hospital--a 39-bed, JCAHO accredited, general, acute care hospital in Martin, Kentucky--had direct management responsibility for several functional departments. In 1992, administration replaced the traditional, hierarchical organization chart with a circular structure that reflected its increased reliance on team processes throughout the organization. The new structure also significantly reduced the number of reporting assignments to the CEO. This article describes the hospital's transition to a team-based organization, illustrates the application of a circular organization chart, and assesses its value and limitations.

Current estimates suggest that over sixty percent of all U.S. hospitals are involved in reengineering initiatives. The level of investment is staggering; literally billions of dollars are being spent in the name of reengineering. Surprisingly little research has been reported, however, aimed at clarifying how this money is being spent (i.e., the content of reengineering) or identifying the management practices that facilitate or impede implementation. This paper summarizes extensive field research from fourteen hospitals across the country aimed at developing a clearer picture of reengineering. The research identifies seven components of hospital reengineering present in various configurations in the hospitals examined. Methods for facilitating reengineering are explored and eight major barriers recognized. Site specific examples are provided to illustrate how the facilitators and barriers work in practice.

This study examines the relationship between outlier status based on adjusted mortality rates and theoretical underlying quality of care in hospitals. We use Monte Carlo stimulation to determine, in the absence of case mix variation, if random variation noise could obscure the signal of differences in underlying rates of quality of care problems. Classification of hospitals as "outliers" is done compared with "true" hospital quality, based on underlying rates for quality of care problems in mortality cases. Predictive error rates with respect to "quality" for both "outlier" and "non-outlier" hospitals are substantial under a variety of patient load and cutoff point choices for determining outlier status. Using overall death rates as an indicator of underlying quality of care problems may lead to substantial predictive error rates, even when adjustment for case mix is excellent. Outlier status should only be used as a screening tool and not as the information provided to the public to make informed choices about hospitals.

Achieving high-quality outcomes in healthcare organizations requires effective systems of control. Such systems consist of formal and informal transactions between patients, providers, payors, and policymakers, among others (Shortell 1972; Stiles and Mick 1997). One method for evaluating the suitability of control-oriented transactions to tasks is to compare the costs of controlling the quality of the good or service produced to the cost of its material and labor inputs. Activity-based cost (ABC) accounting provides the methodology for explicating the causal relationship between healthcare organizations' control-oriented transactions, the services whose quality they ensure, and the costs of both control activities and services delivered. Understanding these relationships is of vital importance to those charged with evaluating the feasibility of proposed managed care contracts, new product lines, and existing service configurations. In this article, we explain why traditional accounting practices are poorly suited to accomplishing the control function in today's healthcare arena, highlight activity-based costing's potential to redress the shortcomings of conventional practice, and elaborate the strategic importance of adopting the new methodology.

The U.S. Department of Veterans Affairs (VA) is undertaking a massive reorganization to transform itself into a more efficient, patient-focused healthcare system. It has developed a new strategy and structure. But if it is to achieve the rapid, sustainable transformation needed to succeed in today's environment, it must also change its culture. The rigid, functionally focused, command-and-control culture that has long been a hallmark of VA must be replaced by one that values speed, flexibility, and the processes for delivering high-quality, cost-effective patient care. Such a change will not come easily. In addition to the normal hurdles, several barriers are unique to VA. They include ingrained bureaucratic traditions and behaviors, constraints imposed by the federal government, close scrutiny by powerful service organizations, and a Civil Service employee base that makes the hiring, promoting, and removing of employees a slow, unwieldy, and procedurally complex exercise. In a climate that does not encourage change, successful transformation must be well orchestrated. To drive the change, the leadership must be mobilized as a team, new work processes must be developed, and a full range of human resource processes must be established.

Increasingly, nonprofit hospital have been responding to market pressures by giving up their tax exemption and selling hospital assets to for-profit corporations. In 1995 alone, fifty-nine nonprofit hospital completed full-asset sales or joint ventures. Hospital managers and board members should understand the legal and regulatory environment surrounding hospital conversions. State attorneys general are taking a more active regulatory role. This discussion describes the application of laws governing charitable trusts and nonprofit corporations to hospital conversions, as well as the central role of the attorney general in the enforcement of such laws. The 1996 Michigan circuit court ruling in Kelley v. MAHSI provides an insightful case study, illustrating a strict application of the law to a joint-venture hospital conversion. The implications of this case will be discussed along with the larger implications of more aggressive state regulation of hospital conversions.

The emergence of visiting consultant clinics (VCC) represents an unstudied but potentially important mechanism for importing specialty physician services into rural areas. An analysis of five years of one state's VCC experience reveals a substantial increase in both availability and geographic accessibility. This study documents the market's response to the oversupply and hypercompetition among urban-based physician specialists. Patterns of VCC growth have varied markedly for different specialties.

The U.S. Department of Veterans Affairs (VA), a large public-sector healthcare delivery system, is following the lead of the private sector in seeking a more integrated approach to providing patient care. The belief is that new entities known as organized delivery systems (ODSs) will produce better, more cost-effective care. Toward this end, VA has reorganized its facilities into 22 networks. The purpose of this paper is to provide VA policymakers and managers with information about building and managing an integrated delivery system for the nation's veterans based on findings from the Health Systems Integration Study (HSIS).

Strategic alliances are proving to be effective strategies for responding and adapting to changing environments, and as such they offer the U.S. Department of Veterans Affairs (VA) healthcare system valuable opportunities for accomplishing the goals of its major reorganization effort. This article begins with an examination of basic strategic-alliance structures that are employed across many different types of industries. Next, consideration is given to the ways in which these basic alliance structures may be adapted to the unique organizations and individuals that serve as providers, purchasers, and consumers of health services. Finally, this article explores how models of strategic alliance in healthcare can be tailored to the specific needs and constraints of the VA healthcare system through an examination of existing and potential alliance opportunities.