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.     

Equity, equity, that's our cry. Interview by Richard L. Reece.

On February 11, 1999, Richard L. Reece, MD, interviewed J.D. Kleinke to talk about his new book entitled Bleeding Edge: The Business of Health Care in the New Century. A medical economist and author living in Denver, Kleinke advocates a true partnership between hospitals and physicians--a marriage with both parties contributing equally to the relationship. He believes that "physicians and people who are running the administrative infrastructures of hospitals and other facilities need to recognize that they are equal partners in a death struggle against the insurers for ultimate control of the premium and the consumer." Though physicians are sure to balk at the suggestion that they become "captive" to the hospital, Kleinke explains that, "captivity is a necessary condition before they can work functionally together and take on managed care and contract directly with consumers, employers, and the government." Kleinke discusses five trends that he explores in his book: risk assumption, consumerism, consolidation, integration, and industralization.     

The minds of a medical director

This article is offered in a nod to all those readers who have been exposed to "whole brain" theory, either through the American College of Physician Executives or elsewhere. As managers struggle with balancing the "left brain" and "right brain" aspects of their work, the author says, they might consider exploiting a third area of activity, or inactivity--the "no brain." This center position can be especially effective in dealing with the high-technology aspects of delivering health care.     

What kind of leaders will be successful?

The U.S. health care system is fundamentally changing. The pace of change is swift but will vary, depending on regional market forces and state legislative mandates. This complex change is leading to rapid market consolidation of providers and insurers into organizations called "integrated health care systems." There is, as yet, no proven role model that will guarantee success. The purpose of this article is two-fold: To help individuals who see an expanding role for themselves in integrated health care management decide if they have what it is going to take to be successful. To identify individual management training needs by use of a self-evaluation tool. Some of the needed skills can be enhanced by education and experience. However, some are personality and style characteristics that may not be changeable.     

Working the truth and perfecting the moment for physicians and patients: a serious challenge for information systems

Most of us can remember the crowning sense of elegance we occasionally felt when we solved a very difficult geometry problem. We linked the proof to the postulates. It was almost like calling on history or the elders to stand silently with us in the flurry of our moment. We "worked truth." I'd like to capture a little of that same "working truth" and apply it in a very unlikely spot: information systems and information technology. It is time to go back and look at the basic postulates of knowledge and responsibility and truthfully apply them in the health care interchange between doctor and patient and make sure that our systems add to and even create an elegance so that the basic relationship of physician and patient in healing can flourish.     

Developing a Subject-Derived Terminology to Describe Perceptions of Chemicals in Foods

Risk perception may be influenced by a number of factors, such as unfamiliarity, lack of control, perceived consequences, and hazards being seen as catastrophic and having risk for future generations. Risk perception researchers have typically used such investigator-selected characteristics to assess hazards. In the first study reported here, the repertory grid method was used to elicit the terminology that subjects ( n = 30) use to distinguish between 30 different chemicals. The data were submitted to generalized Procrustes analysis. The first principal axis of the resulting consensus plot separated the chemicals ranging from "poisonous or toxic,""harmful or dangerous," and "sounds negative" at one end, to "positive effect on health,""often present in food nowadays," and "sounds positive" at the other end. The second principal axis ranged from "familiar with or knowledge of" and "chemical" to "natural." A second study ( n = 226) was carried out to look at the general validity of the results of the repertory grid interviews using a fixed questionnaire. The data were submitted to principal components analysis and internal preference mapping. The first principal component ranged from "safe" and "healthy" at one end, to "poisonous" and "harmful" at the other end. The chemicals also separated in terms of "familiar,""chemical," and "natural." All three methods of data collection and analysis yield essentially similar results.     

Finding the essential difference

The idea of what is essential and what is peripheral is basic to all intelligent management of change. At the core of all our resistance to change is the fear that we will lose something of ourselves, something unrecoverable. "Touching ground"--gaining clarity on what we are truly about, and shaping our strategies around that core--is a key skill of the change master. What is the most important element in helping people deal with change? According to Roger Fritz, President of Leadership by Design, Inc., a St. Louis consulting firm, "Helping them recognize what's essential. There are two kinds of change: Technical change and profound change. A technical change asks you to learn something different. A profound change ask you to be someone different." Too often, we confuse the two and are met with resistance.     

Preserving the soul of medicine and physicians: a talk with David Whyte. Interview by Richard L. Reece

Richard L. Reece, MD, interviewed David Whyte, a poet, consultant, and author of The Heart Aroused, on December 15, 1999, to discuss preserving the soul of physicians in corporate America. David describes the soul as "a measure of our belonging in the world. When there is little sense of belonging, there is very little sense of soul." In the workplace, he thinks about whether "people have a sense of belonging to the particular work or the organization." He talks about life in the upper world of the workplace and life in the dark subterranean caves where the soul lives. The soul is where people's true creativity and imagination resides ... and by inviting it into the workplace, organizations and employees can become more successful, innovative, and adaptable. In corporate settings, he uses poetry to bring an understanding of the process of change, helping clients to understand individual and organizational creativity to transform the workplace. The poetry can teach and touch those places that the corporate language cannot speak to.     

360裂变 奇虎进化密码

短短6年时间,奇虎360在"免费安全"的基础上,完成了商业模式的五次内涵式、有机式进化。当年一款看似无心插柳的浏览器产品,最终却成为了支撑奇虎变现海量用户的关键基石。     

Public health infrastructure: creating a solid foundation

The nation's public health system remains in disarray, despite the 1988 warning by the Institute of Medicine in its landmark report, "The Future of Public Health." Recent concerns about antibiotic resistance, inadequate disease surveillance capabilities, bioterrorism, and an increasing need for training the public health workforce have brought this problem into the forefront of congressional concern. Recent legislation aimed at addressing this problem was passed last Fall and signed into law. This program will take a significant step towards ensuring a solid public health system when it is fully implemented.     

Communication skills: a prerequisite for leadership

A man once said, "He who would be first among you, let him be your servant." I think he also would have said, "If you would be the leader of the troops in health care, you must be able to communicate." You must be a good listener, be able to facilitate conflict resolution, be a good interviewer, deal effectively with problem physicians and employees, speak effectively in front of an audience, and communicate well in writing. Do not assume that you are good at any of these skills because you went to medical school. All of us need improvement in these areas.     

Understanding Consumer Confidence in the Safety of Food: Its Two-Dimensional Structure and Determinants

Understanding of the determinants of consumer confidence in the safety of food is important if effective risk management and communication are to be developed. In the research reported here, we attempt to understand the roles of consumer trust in actors in the food chain and regulators, consumer recall of food safety incidents, consumer perceptions regarding the safety of particular product groups, personality characteristics, and sociodemographics, as potential determinants of consumer confidence in the safety of food. Consumer confidence in the safety of food was conceptualized as consisting of two distinct dimensions, namely, "optimism" and "pessimism." On the basis of a representative sample of 657 Dutch consumers, structural equation modeling was applied to simultaneously estimate the effect of the determinants on both "optimism" and "pessimism." The results indicated that, to a considerable extent, both optimism and pessimism about the safety of food arise from consumer trust in regulators and actors in the food chain and the perceived safety of meat and fish rather than other product categories. In addition, support was found for the notion that optimism and pessimism are conceptually distinct, as these dimensions of confidence were partly influenced by different determinants. The results of this study imply that consumer confidence in the safety of food could be enhanced by improving both consumer trust in societal actors, and consumer safety perceptions of particular product groups.     

An emergency department perspective--Part III, Outcomes

The outcome of care has traditionally been defined as a "change in the patient's current and future health status that can be attributed to antecedent health care." However, this definition provides a "unidimensional view of quality." It fails to take into account the customer's attributes and the many small steps or process variances that can contribute to an unexpected outcome. This failure can be especially pronounced in the emergency department.     

Heaping in anniversary reaction studies: a cautionary note

Several studies have reported evidence that death is often associated with significant ceremonial events like holidays and birthdays, a phenomenon variously called the "anniversary reaction," "holiday effect," "birthday blues," etc. This article, using data from the social security death index (SSDI), shows how evidence for this phenomenon can arise from an artifact in death records called "death heaping" in which certain dates, usually the 1st or the 15th, are systematically entered for missing data. In this study, each calendar birthday for the year 2003 in the SSDI was paired with either the 14th or 15th calendar day of death. For each pairing, there were more deaths for the 15th than the 14th. A second analysis compared the correspondence between dying on the same day of the month as one's birthday for the first 28 days of the month. A significantly greater number of birth-death combinations occurred for the 1st and 15th day of the month. These results suggest that studies of "anniversary reactions" should conduct preliminary evaluations to consider the possibility that statistically significant relationships do not arise from "death heaping."     

A theory of organizational response to hospital regulation: a reply to Smith and Mick

Smith and Mick identify four basic problems with the theory the present writers developed to explain organizational responses (in this case the behavior of hospitals) to regulation. They challenge the basic assumption regarding autonomy, disagree with the implied cause and effect relations between organizational response and regulation, criticize the omission of goals, and claim that the theory has only limited generality. In so doing they state that their primary concern is with "improving our understanding of the limitations and benefits of the theory." Each of the four topics they raise for consideration will receive comment.     

Statistical Issues in the Estimation of Assigned Shares for Carcinogenesis Liability

Congress is currently considering adopting a mathematical formula to assign shares in cancer causation to specific doses of radiation, for use in establishing liability and compensation awards. The proposed formula, if it were sound, would allow difficult problems in tort law and public policy to be resolved by reference to tabulated "probabilities of causation." This article examines the statistical and conceptual bases for the proposed methodology. We find that the proposed formula is incorrect as an expression for "probability and causation," that it implies hidden, debatable policy judgments in its treatment of factor interactions and uncertainties, and that it can not in general be quantified with sufficient precision to be useful. Three generic sources of statistical uncertainty are identified--sampling variability, population heterogeneity, and error propagation--that prevent accurate quantification of "assigned shares." These uncertainties arise whenever aggregate epidemiological or risk data are used to draw causal inferences about individual cases.     

Management competencies required in ambulatory care settings

A study was conducted to identify the most important competencies physician executives in medical groups and other ambulatory settings will need to have in the next five years. The specific job skills, knowledge, and abilities (SKA) that physician executives will need to acquire these competencies were also explored. The Delphi techniques were used to analyze responses from two surveys from members of the American College of Medical Practice Executives. The most important competencies were grouped into 13 management domains, each with specific SKAs. "Managing health care resources to create quality and value" and "fundamentals of business and finance" were rated as the most important competencies. The most frequently rated SKA was the "ability to build and maintain credibility and trust."     

The courageous follower

With the recent changes in the delivery of medical care in the United States, physicians are being thrust into new and unsettling roles. Many are finding themselves for the first time in the role of the follower, subject to myriad types of leadership. Leaders frequently complain that leading physicians is like "herding cats." What are the characteristics of followers? Do physicians make good followers? This article examines the role of the "cats"--what is effective followership, why physicians may fall short in followership skills, and how physicians might become better "followers."     

中国式管理与中国管理模式的理论辨析

中国式管理与中国管理模式貌似相同,实则有很大差别。二者在理论来源上,有"中国传统哲学+西方现代管理科学+中国古代行政管理实践"与"中国管理哲学+西方现代管理科学+中国现代企业管理实践"的差别;在生成根基上,有农业经济与工业经济及知识经济的差别;在建构前提上,有等级与平等的差别;在核心内容上,有管与理的差别;在表现形式上,有零散与体系的差别;在应用特性上,有灵活机智与可复制性的差别;在追求目标上,有保持组织稳定与促进组织发展的差别。     

Public Perceptions of the Potential Hazards Associated with Food Production and Food Consumption: An Empirical Study

Although public perceptions of food-related hazards receive much media comment and debate, the research literature on such perceptions is sparse and piecemeal. In the reported study, 216 people completed a questionnaire relating to their perceptions of the "risk characteristics" of potential hazards associated with various aspects of food production and food consumption. Responses were examined via principal-components analysis to obtain a structural representation of risk perception of the kind provided by Fischhoff, Slovic, and their colleagues in their seminal psychometric work.^(1,2) A three-component solution accounting for 87% of the variance was obtained, with the dimensions labeled as "severity,""unknown," and "number of people exposed." The findings also yielded information pointing to evidence of the phenomenon of unrealistic optimism. We conclude that our findings offer a useful base upon which further in-depth research integrating different perspectives on risk perception with respect to food-related hazards may be developed.