Building a framework to transform health care

Advances in information technology are helping clinicians to realize the promise of evidence-based medicine, which includes benchmarking, outcomes monitoring, predictive modeling, and clinical pathways. By integrating individual clinical expertise and the best available research, physicians can apply the disciplines and techniques of clinical research to their practice of medicine, one patient at a time. Evidence-based medicine also allows organizations to move forward with continuous clinical quality improvement programs. Standards, open systems, data warehouses, and evidence-based medicine help a health care delivery system obtain the technical infrastructure, decision-making processes, analytical skills, clinical databases, predictive models, and clinical pathways. With this information technology (1) physicians can practice evidence-based medicine and (2) the delivery system can profile clinicians' practice habits for managed care contracting and continuous clinical quality improvement.     

Benchmarking: the key to influencing physicians

Managing physicians to achieve cost reductions can seem impossible, especially when managed care penetration is low. Physicians feel little pressure to change when asked merely to cut costs, especially when their boat is not rocking. But physicians will respond to benchmarking data on CPT-coded procedures that are directly comparable to their own practices. When surgeons see that others take less time to perform a procedure and/or use fewer and lower cost supplies, their competitive spirits are aroused. They become inquisitive about why this is so and then are eager to change by trying new methods and improving their techniques. Science is the key motivator, not savings. When benchmarking recommendations are implemented in a facility, better practice and substantial cost savings are the positive results.     

Medical staff handling of concerns with physicians' performance

Medical staff organizations and their leaders are frequently confronted with concerns about physician knowledge, performance, or behavior. Dealing with these concerns is a serious and time-consuming task. Poorly handled issues may result in serious legal consequences. In highly structured organizations, authority for responsibilities, income, and employment rests with individuals who must manage these problems, but medical staff structures do not always lend themselves to dealing with these issues. Introduction of quality improvement processes into medicine has been received as a panacea for physician problems. Certainly the majority of physicians understand quality improvement and work toward common goals to improve patient care. Unfortunately, a small minority remain problem physicians. Steps that can be taken to deal with problem physicians, particularly for issues of quality management, are described in this article.     

Best practices in business process redesign: an overview and qualitative evaluation of successful redesign heuristics

To implement business process redesign several best practices can be distinguished. This paper gives an overview of heuristic rules that can support practitioners to develop a business process design that is a radical improvement of a current design. The emphasis is on the mechanics of the process, rather than on behavioral or change management aspects. The various best practices are derived from a wide literature survey and supplemented with experiences of the authors. To evaluate the impact of each best practice along the dimensions of cost, flexibility, time and quality, a conceptual framework is presented that synthesizes views from areas such as information systems development, enterprise modeling and workflow management. The best practices are thought to have a wide applicability across various industries and business processes. They can be used as a “check list” for process redesign under the umbrella of diverse management approaches such as Total Cycle Time compression, the Lean Enterprise and Constraints Management.     

The medical director as educator: an interview with Elizabeth M. Gallup, MD, JD, MBA. Interview by Richard L. Reece

Richard L. Reece, MD, interviewed Elizabeth M. Gallup, MD, JD, MBA, on July 9, 1999, to talk about the evolving role of the physician executive. Dr. Gallup discusses how medical directors have evolved from a purely clinical role to participating in the business side of medicine as well. The traditional medical director, a Dr. No who denies treatment and watches clinical performance, is now becoming an educator helping physicians to manage their behavior and change their practices based on comparative data. Her book, How Physicians Can Avoid Surrender and Lead Change: Gaining Real Influence in Your Own Health Care Organization Before It's Too Late, (American College of Physician Executives, 1996) promotes acting together as a group if physicians want to stay independent and not become employed. Independent physicians can form IPAs and act together as a group, avoiding some antitrust laws. Unless physicians get together and act as a group, she says, they are doomed to further and further erosion of their economic interests as well as their clinical autonomy.     

A comparison of quality and utilization problems in large and small group practices

Physicians practicing in large, multispecialty medical groups share an organizational culture that differs from that of physicians in small or independent practices. Since 1980, there has been a sharp increase in the size of multispecialty group practice organizations, in part because of increased efficiencies of large group practices. The greater number of physicians and support personnel in a large group practice also requires a relatively more sophisticated management structure. The efficiencies, conveniences, and management structure of a large group practice provide an optimal environment to practice medicine. However, a search of the literature found no data linking a large group practice environment to practice outcomes. The purpose of the study reported in this article was to determine if physicians in large practices have fewer quality and utilization problems than physicians in small or independent practices.     

TQM in health care: mistaken identity?

Total Quality Management is a powerful tool in health care today. The definition of quality improvement in the medical literature focuses on improving patient outcomes. However, most quality initiatives in the health care field focus on improving productivity, cost-effectiveness, market share, employee morale, and efficiencies of processes. This disparity between the medical definition of quality and the actual application of quality improvement may have the effect of alienating many physicians, the very people who must be involved. The semantics are important to address in a TQM initiative.     

Implementing TQM in a medical school department

In a modest way, our medical school department has succeeded in applying continuous quality improvement and TQM methods to its ambulatory practice. We are close enough to our experience not to have forgotten what Rosabeth Moss Kanter calls the "messy, mistake-ridden, muddling stage." This article is a narrative of some of our stumbling attempts to change the way our practice works. The lessons we have learned are relevant to other ambulatory practices, both inside and outside the academic world.     

Physician acceptance of new medical information systems: the field of dreams

Physicians often fail to embrace a complex information system, may not see its relevance to their practices, and are characteristically reluctant to invest the time and energy to be trained in its use. Why is widespread physician buy-in so difficult to achieve? From physicians overwhelmed with change to failing to begin with an adequate physician base of support, this article explores some of the reasons that physicians demonstrate little buy-in to this process and offers suggestions to help create a more successful implementation. Ways to build acceptance include acknowledging the importance of physicians as customers and training them early and often.     

No going back: A review of the literature on sustaining organizational change

Why do some organizational changes persist, while others decay? The sustainability of change can be defined broadly as the process through which new working methods, performance goals and improvement trajectories are maintained for a period appropriate to a given context. However, sustainability has received limited attention, although the concept reflects Lewin's concern with ‘refreezing’ ( Lewin. K. 1951 . Field Theory in Social Science: Selected Theoretical Papers by Kurt Lewin, UK edition published 1952, ed. D. Cartwright, London: Tavistock). In an uncertain environment, working practices that fail to adapt are targets for change, and stability has been regarded not as a condition to be achieved, but as a symptom of inertia, a problem to be solved. This paper reviews the emerging literature, seeking to develop a provisional model of the processes influencing change sustainability and decay, as a platform for further research. This review suggests that sustainability is dependent on multiple factors, at different levels of analysis: substantial, individual, managerial, financial, leadership, organizational, cultural, political, processual, contextual and temporal. The relative significance of those factors cannot be determined a priori, raising questions concerning the properties of the sustainability process with regard to different types of change in different contexts.     

The impact of manufacturing and supply chain improvement initiatives: A survey comparing make-to-order and make-to-stock firms

Manufacturing firms aim at improving both internal and external processes to improve the competitive advantage. Such initiatives include lean practices as well as supplier rationalization and integration. In this paper, we analyze these improvement initiatives and their impact on business performance. In particular, we explore potential differences between make-to-order (MTO) and make-to-stock (MTS) firms. We use data from 216 Australian manufacturing firms. We find a clear difference of improvement focus between MTO and MTS firms. MTO firms exhibit a significant impact of supplier integration on business performance, but not for lean practices and supplier rationalization. The situation is completely reversed for MTS firms, since they have significant effects for internal lean practices and supplier rationalization, but not for logistics integration with supplier. The results show that the distinction between MTO and MTS firms is important when analyzing manufacturing and supply chain improvement initiatives.     

Benefits of adopting lean production on green performance of SMEs: a case study

Abstract

Small- and medium-sized enterprises (SMEs) are widely recommended to strive, not only for their performance in operational side, but they need to integrate the environmental dimension. To do that, the literature widely indicates a positive impact of lean practices on green performance. However, very few studies have been carried out in SMEs context. In this view, this paper aims at providing through a practical case study of lean implementation in a real-life small manufacturing company, the information to confirm this synergy between lean and green performance. To achieve this aim, a proposed framework of lean and green integration has been implemented in a SME producing different types of pumps. The results achieved shows that there is a strong correlation between operational metrics improvement and green metrics improvement. Moreover, the benefits of lean practices such as 5S, Kanban, SMED, AM, cellular manufacturing and quality control on green performance are widely demonstrated. Future work could study other processes and explore other case-specific supporting tools and techniques.     

Resolving conflicts: principles and practice

Physicians and other medical professionals undergo extensive professional training for the privilege of obtaining their professional licenses. For most physicians, clinical training is conducted in extremely competitive circumstances. Many physicians endorse competition as an appropriate method for producing greater individual and collective competence within the profession. Competition, however, is a very limited way to resolve conflicts. And, in the current environment of greater resource restrictions and reform, the competitive model, at best, seems short-sighted. Many of the current relationships involving physicians and others are transitional, involving various partners in numerous practice and professional relationships. For example, medical practices are merging; hospitals are engaging physicians in numerous business structures, even employment. However, longer term relationships are enhanced by mutual respect and collaboration, rather than chronic competition to "win" one's rights over another. Thus, the need among physicians to enhance their conflict resolution skills is expanded in today's environment.     

Combining information about process and outcomes to improve clinical care

For some managers, clinical quality improvement begins and ends with measuring the clinical outcomes of care. For others, analyzing and altering processes of care are the central focus. To remove quality improvement from the realm of guesswork, these approaches must be intertwined. In health care, this linkage has appeared elusive. Now, using decision theory, there is a way.     

Twenty steps to survive managed care.

The health care industry is in the midst of discounted, price-driven, managed care. Many older physicians, not wanting to practice in this environment, are opting for early retirement. Others sell their clinical practices to management companies or hospitals to avoid the economic reality of day-to-day financial management. Most of these private practices are losing money every year. However, there still are a large number of physicians who have not sold their practice. As capitation continues to grow, these physicians will experience severe cash flow problems unless their financial plight is addressed rapidly. If it is not, the resultant cash flow problems will cause accounts payable to grow. Twenty steps are outlined that a physician or group should take right away to maintain a healthy cash flow. These include: Instituting a nurse triage system, setting up an after-hours clinic, getting the co-pay at the time of service, implementing a patient satisfaction questionnaire, monitoring the capitation reports, and checking capitation lists.     

A strategy for incorporting ISO 9000 into an internationally oriented accounting practice

Management consulting organizations generally can plan to improve their earnings by two strategies. First, they can offer their services in a more efficient manner by using a minimum amount of resources. This is normally accomplished by employing common tools such as reengineering of the processes, continuous improvement, and target costing. Second, they can attempt to raise their market share or offer new types of services required by clients. For accounting firms, this means expanding their service horizons from traditional audit, tax, and systems consulting to more contemporary areas such as ISO 9000 and total quality management (TQM). The authors outline an approach for firms to successfully undertake the inclusion of quality audit services in their practices.     

Value-based health care. Part I: Physicians reestablishing clinical autonomy

Clinical decision-making was once the sole purview of physicians, but no longer. Medical judgment has been usurped by third parties in the name of cost control. To reestablish this rightful authority, physicians must organize to assume the financial risks for their patients' health, using objective, clinical information to deliver superior quality outcomes. To successfully manage their patients' clinical and financial risks, physicians need to: (1) establish a structure independent of the hospital medical staff for outpatient contracting; (2) secure a capital partner that supports their independent, clinical decision-making; and (3) be leaders in acquiring and effectively using clinical information that accurately risk-adjusts and integrates both inpatient and outpatient data for all episodes of care. Physicians who acquire these skills will secure premium contracts from purchasers who are demanding value-based health care delivery.     

The management accountant's role in quality management: A Queensland perspective

The successful implementation of quality management (QM) requires a change in both an organization's culture and structure. Consequently, as management accountants are organizational members their roles and systems will need to change to provide support for this QM implementation. This study found that although the majority of management accountants are involved in the implementation of quality concepts into the accounting area of the firm, there has been little modification of cost determination methods and limited development and use of quality related performance measures. Nevertheless, the overall results of this research imply that the role of the management accountant has altered due to the implementation of QM practices, but not to the degree indicated in the literature.     

A review of the Chinese cultural influences on Chinese enterprise management

In order to create and sustain competitive advantage, a company should not only develop technologies to create products and processes that meet customer needs, but also stimulate a corporate culture that commits to continuous performance improvement. Managing corporate culture is one of a number of important factors that make for organizational change and business success. This paper reviews the cultural roots and identifies the characteristics of Chinese cultural values and management. A comparative analysis of the differences between Anglo-American and Chinese cultures is made. The cultural influences on Chinese management systems are then elaborated with reference to enterprise management in Mainland China and Hong Kong. With unique cultural heritage, collective orientation has a pervasive influence on the mode of Chinese management and organization. The prevailing Chinese culture values stress largely the paternalistic approach to management, acceptance of hierarchy and the importance of relationships. Today's Chinese enterprises need to determine changes in practice or value or both aspects of corporate culture in order to facilitate organizational change and maintain a competitive edge over their rivals. The paper also discusses the links of cultural values to employee involvement (EI) and total quality management (TQM), and initiates a need to manage cultural influences on EI/TQM practices to improve organizational performance in Chinese enterprises.     

Improving performance in a contracted physician network

Health care organizations face significant performance challenges. Achieving desired results requires the highest level of partnership with independent physicians. Tufts Health Plan invited medical directors of its affiliated groups to participate in a leadership development process to improve clinical, service, and business performance. The design included performance review, gap analysis, priority setting, improvement work plans, and defining the optimum practice culture. Medical directors practiced core leadership capabilities, including building a shared context, getting physician buy-in, and managing outliers. The peer learning environment has been sustained in redesigned medical directors' meetings. There has been significant performance improvement in several practices and enhanced relations between the health plan and medical directors.