Medical care review最新文献

The change in reimbursement and turbulence in the external environment are elements of uncertainty to all hospitals, including university hospitals. The organizational character of the university hospital presents it with substantial challenges as it strives to continue to meet its traditional role in society. Changes in policy may indeed be enacted with specific outcomes in mind--but they may result in totally unexpected longer-term effects on the institutions affected. This article--an attempt to develop a model and a set of propositions through which such changes can be analyzed as they affect the university hospital and its relationship to its medical faculty/staff--focuses primarily on the effects of such changes on the delivery of clinical services. While individuals viewing the same problem from different perspectives could reach other conclusions regarding academic activities and community services, the approach may be useful as an analytic tool for these areas of concern as well. For the sake of simplicity and because patient care is important both clinically and financially to the university hospital, it was chosen as the critical variable on which to focus the analysis. The analysis was predicated on the interaction of two perspectives from the general area of exchange theory. While each can contribute to an understanding of the dynamics of organizational change, their complementary nature allows one to analyze organizational environments from a more inclusive perspective. It is suggested that changes in policy that result in changes in organizational performance should utilize frameworks that integrate perspectives--focusing on commonalities, identifying differences and, in essence, triangulating on the management of critical relationships--to ensure successful implementation of the policy change. In this way, the analytic framework developed in this article should be useful as a close reflection of organizational reality. Prospective payment, price competition, alternative sources of care, and the oversupply of physicians threaten to change the balance of influence among the university hospital's influential actors. Depending on the decisions made, any of the four goals of the university hospital (patient care, education, research, and community service) may have to be modified or eliminated. The university hospital's historical role as the last resort for the severely ill, developer of new basic and clinical knowledge, and provider of indigent care may be in jeopardy. While the long-term effects of PPS and competition for patients cannot be predicted, speculation can be offered regarding the possibility of changes in the traditional physician-patient and faculty/staff-university hospital relationships as both institutional and external regulators and purchasers of care exert increased control over UH physicians. Such changes may lead to an under-supply of physician educators and physician scientists as a result of a change in

Over the past decade the importance of governing boards as policy-making setting and oversight units within organizations has increased dramatically. Although this is true for both corporate- and private-sector organizations (Bacon and Brown 1977; Gelman 1988), it is particularly relevant to the health sector. Hospital governing boards, long considered inconsequential in hospital management, have recently become subject to closer scrutiny. The role of governing boards in decisions affecting hospital strategy and hospital performance is once again a topic of some interest in boardrooms and hospital trade journals. Impressive evidence of the renewed interest in governance is provided by the funding of an instructional consortium by the S.K. Kellogg Foundation to help strengthen trusteeship and governing board decision making, and to improve education for health services managers in the area of governance. Members of the consortium include the Hospital Research and Educational Trust, the American Hospital Association, the American College of Healthcare Executives, and the Association for University Programs in Health Administration. Among the activities being undertaken by this consortium is the development of a self-assessment tool/methodology for boards, a bibliography and reference guide on effective governance for practicing trustees, research workshops for faculty in health administration programs, and a teaching guide on governance and trustee leadership. Despite this interest, the question with which we began this article persists. Do governing boards make a difference? In the course of our review of previous work on governance we found that, more often than not, that question has been transformed into: how do boards influence hospital performance? And very often that question has been further narrowed into: which board structure leads to better hospital performance? We have argued for a respecification of the initial question. Rather than pursuing a definition of the maximally performing governing board, we should perhaps shift our focus back to a fuller understanding of board structure and function, and its influence on hospital change. The model developed here combines four essential, and very basic, questions: 1. What are the basic dimensions that underlie structural variation in different types of governing boards? 2. How do these board types influence structural change in hospitals? 3. How is the effect of board influence on change itself likely to change over time as a function of the hospital's general pattern of growth, decline, stability, or instability?(ABSTRACT TRUNCATED AT 400 WORDS)

One of the most compelling issues in United States health policy in the 1980s has been the growing number and proportion of the population with no health care coverage--no private health insurance, no Medicare coverage, no Medicaid coverage, no coverage through any other public or private program. Those without any coverage for health care expenses have come to be known as "the uninsured." The uninsured have increased from 27 million, 13 percent of the total population, in 1977 (Kasper, Walden, and Wilensky n.d.) to 37 million, 16 percent of the population, in 1987 (Short, Monheit, and Beauregard 1988). This article examines the reasons why health insurance coverage is an important issue, those groups most likely to be uninsured, the major sources and types of coverage for the insured population, and public policy options being considered to address the problem of access to health insurance.

In reviewing the literature and research on leadership, as conceptualized in the rational and natural system perspectives, we identified major trends and issues in the organizational literature on leadership. Our discussion of the implications of this literature for the study of health services organizations raised several questions, and identified them for future research.