Cost-effective rehabilitation: Part 1--Basic principles

Patients may be referred for rehabilitation services with a variety of diagnoses, including stroke, spinal cord injury, brain injury, multiple trauma, orthopedic disorders, arthritis, multiple medical problems, and chronic pain. The goals and endpoints for treatment of these conditions are often unclear. The principles that are described in this article provide a structure for creating efficient and effective rehabilitation treatment plans. These principles can also focus the utilization and peer review processes and can assist in determining medical necessity of rehabilitation services. Part one of this two-part article discusses general principles of cost-effective rehabilitation. Part two, in the December 1995 issue, will focus on individual patient management issues.     

Risk management in an IPA setting--Part II

In the first part of this two-part article, the author explored the nature and significance of differences in the levels of risk in IPA and network managed care settings. In this concluding part of the article, he describes and assesses methods that may be undertaken by the IPA-model HMO to control and minimize risk elements. In short, what follows are the elements of a risk management program in such an environment.     

Medically necessary?

Coverage decisions can ultimately be traced back to three words in the original health policy contract: medically necessary and investigational. Investigational as a coverage exclusion applies to the minority of cases, in which there is inadequate data to validate the effectiveness of the intervention. In contrast, the majority of coverage decisions are based on medical necessity. Over the years the concept of medical necessity has evolved to encompass a multitude of medical management strategies. This discussion highlights the variable uses of the concept of medical necessity in terms of: (1) Determining the most appropriate intensity of service and place of service; (2) determining whether the proposed therapy is medically appropriate for the patient's condition; (3) distinguishing between medically necessary services and those that are performance enhancing or discretionary in nature; (4) making a distinction between medically necessary, cosmetic, and reconstructive services; and (5) defining medical necessity in accordance with generally accepted principles of good medical practice.     

Working with an executive search firm: Part I--The candidate's perspective

This article is the first in a two-part series on how to work with executive search firms. Part one describes how the physician executive can build an effective relationship with an executive search firm as a candidate or potential candidate. Part two will cover how the physician executive can work with an executive search firm--either as a client or as a member of an executive search committee--to attract high-quality management talent.     

A protocol for mutual respect and communication

Physicians relating to each other, discussing a patient's problem, needs, and care plans, should be the easiest part of medical practice. Unfortunately, exchanging meaningful information between physicians and their offices is, at times, formidable. This article describes the guiding principles for physician referrals at Hamot Medical Center that were developed to enhance communication between physicians and increase patient care.     

An emergency department perspective: Part II. Process review

Webster defines process as a "series of actions or operations conducting to an end." Each of the many processes that may be involved with providing a service or procedure comprises many smaller steps. It is the monitoring of those steps that we call a process review. The process review for quality management begins when a patient perceives the need to receive emergency care. It embodies the technical and interpersonal aspects of the patients, and the staff's interpersonal relationships.     

Patient dynamics, staff burnout, and consultation-liaison psychiatry

This paper discusses the valuable role of the consultation-liaison psychiatrist in reducing hospital staff burnout, particularly in working with difficult patients admitted to nonpsychiatric services. Direct patient consultation is a reimbursable service. However, staff-oriented consultation, while not reimbursed by most third-party payers, can be an invaluable means of improving staff-patient relations, reducing liability risk, and alleviating staff stress. The consultation-liaison psychiatrist can be an important element in a hospitalwide, ongoing, comprehensive program to reduce burnout and thereby optimize staff retention and staff effectiveness.     

Working with an executive search firm: Part II--The hiring organization's perspective

This article is the second part in a two-part series on how to work with an executive search firm. The first article, which appeared in the September-October 1992 issue of Physician Executive, focused on executive search from the candidate's perspective. This article focuses on how organizations can work with an executive search firm to recruit and retain top management talent.     

What Management Style is Considered Best for a Team-Based Organization and Why?

The paper reviews various styles of management that are commonly employed for managing team-based programs and projects in many manufacturing industries. It analyzes the characteristics of each style with respect to the needs for decomposing the goals into smaller chunks in a team-based organization or in a program. Three styles of management were considered at Electronic Data Systems (EDS) for this analysis. Based on the experiences of applying each style during various team-based programs at EDS, Ford Motor Company, General Motors, and Unigraphics Solutions accounts and from the varying degree of success achieved then, the paper points out which management style is well suited for managing this decomposed set of goals and why. It then analyzes which style is best suited for managing a team-based organization. As W. Edward Deming said in his book The New Economics, setting a particular numerical goal accomplishes nothing. Setting a method to achieve a common set of consistent goals is important. Clear and consistent set of decomposed goals provides a `constancy-of-purpose.' Without a common subset of consistent goals identified for each concurrent team (decomposed from its original sets), the product development teams do not know what is expected from each other and how to accomplish the tasks concurrently. Finally, the paper discusses why a management style, which is based on a set of constancy-of-purpose (governing) principles, is considered superior for managing a team-based organization.     

企业信息技术管理组织模式及其历史演进

信息化时代,企业对信息技术的使用不仅是IT技术开发应用和系统操作维护的问题,更是一种对专门化服务的管理问题。对企业信息技术管理的组织体制设计,将在很大程度上决定这个企业能否有效地利用信息技术作用来提升其竞争和发展的能力。本文试图从历史发展进程角度分析和评价企业信息技术管理可资采用的几种典型组织模式及其各自的优缺点和适用条件,以对全能型单位剥离辅助业务提供一些操作性的指导意见。     

Modern health care depends on technology, Part 2

The first article in this series presented the principles and vocabulary of technology assessment and described the process used at St. Luke's, a tertiary care hospital in Bethlehem, Pennsylvania. This second article will describe the resources needed to support a technology assessment program. Technology planning, acquisition, and management will also be discussed. Historically, the health care marketplace has welcomed new technologies. In a future in which providers will be accountable for the outcomes of the care they provide, the ability to evaluate new and existing technologies will be essential for success.     

Information technology enters the doctor's office: Part I--Six design and implementation lessons

Because of a trend toward increased cost escalation outside of the hospital, in the ambulatory care setting, Metropolitan Life Insurance Company initiated an Ambulatory Utilization Review ("AUR") program in 1986. This is an overview of the lessons learned since that time. Some of what was learned was simply--or not so simply--"how to," the subject of this first article in a two-part series. Once this deceptively difficult technology was understood, there were two additional categories of lessons to learn: the extent of expected program results and some unexpected results. This second set of lessons is reviewed in Part II of the article.     

Spirituality and the physician executive

The "s" word can now be spoken without flinching in health care organizations. Spirituality is becoming a common topic in management conferences around the world. Many U.S. corporations are recognizing the role of spirituality in creating a new humanistic capitalism that manages beyond the bottom line. Spirituality refers to a broad set of principles that transcend all religions. It is the relationship between yourself and something larger, such as the good of your patient or the welfare of the community. Spirituality means being in right relationship to all that is and understanding the mutual interdependence of all living beings. Physician executives should be primary proponents of spirituality in their organizations by: Modeling the power of spirituality in their own lives; integrating spiritual methodologies into clinical practice; fostering an integrative approach to patient care; encouraging the organization to tithe its profits for unmet community health needs; supporting collaborative efforts to improve the health of the community; and creating healing environments.     

Utilization management key to HMO success.

Utilization management has a long history in prepaid health programs, especially in capitated, prepaid risk programs that were the precursors of HMOs. Utilization management is commonly considered to be that set of systems and procedures used to ensure that a patient's medical needs are met at the least cost possible consistent with adequate quality. Examples of measures taken in managing utilization include avoiding unnecessary surgery, unnecessary hospitalization, excessive hospitalization, and unnecessary diagnostic and therapeutic measures, and encouraging use of less expensive means of care, such as home health care services. Also included, and of great importance, is obtaining those services at the least possible cost through favorable contracting for services.     

Potential psychodynamic factors in physician-assisted suicide

A number of assumptions underlying the debate over physician-assisted suicide (PAS) deserve closer scrutiny. It is often implicitly assumed that decisions as to the competency of the patient to request PAS can be accurately made, and that the treating physician's values and intrapsychic conflicts can be successfully separated from the decision to accede to or reject the patient's request. This article argues that in such an emotionally-laden decision, such factors may play a significant role, and that even were PAS to gain widespread acceptance, ignoring them may lead to errors in classifying patients either as appropriate or inappropriate for PAS.     

Stepping stones,step change,and climate change: Why muddling through is insufficient

Part One of this two-part series on the U.S. Environmental Protection Agency's (EPA) efforts to reinvent environmental regulation described the key elements of a new, performance-based environmental management system and illustrated why new economic and environmental problems demand the immediate design and implementaion of such a system. This installment identifies some of the sociopolitical factors in the United States that favor incremental modifications to the current system rather than the addition of the more modern performance-focused system.     

Reporting quality of health care to the board

The reporting of quality of health care to the governing board has long been an enigma. Now we are in the midst of a revolution in health care, as we shift our focus from solely the clinical performance of individuals to a broader scope of assessing and improving all activities around patient services and patient care--i.e., management outcomes integrated with clinical outcomes to help identify opportunities to improve patient care. In addition, apprised of corporate liability for the quality of care provided in health care organizations, governing boards are raising questions and demanding more information. To maintain this high degree of interest in quality of health care, information should be restricted to what the board needs to know. This article will be confined to the hospital's organizationwide quality system of monitoring and evaluating. While medical staff credentialing and privileging are also board responsibilities and quality management activities should be used in the privileging and credentialing process, they will not be addressed in this article.     

A cost containment program targeting home infusion drug therapy

A program was instituted to determine if retrospective, concurrent, and prospective analysis of home infusion therapy cases by a multidisciplinary team comprising clinicians and financial analysts would lead to cost reductions and cost-effective behavioral changes by providers. Actual invoices and prospective price quotes for infusion therapy were reviewed and compared to a database of "usual and customary" prices. The results were presented to providers with the intent of obtaining a reduction in prices for the services rendered or about to be rendered. As a result, $3,265,248 in short-term cost reductions were achieved, and $15,146,789 in long-term cost reductions are projected. Analysis resulted in average cost reductions of $2,247 and $10,424 respectively. Very significant cost reductions can be achieved through the use of a multidisciplinary team and a comprehensive pricing database for home infusion therapy.     

The green company: A case of labor management and employee empowerment in a small business

The basis of this teaching case is a small nursery and landscape business in the Northeast United States. The case describes how the company attempted to implement a decentralization and employee empowerment program to move relevant decision-making closer to the work site. It illustrates that shifting from a centralized top-down style of management to a decentralized incentive driven style can create many challenges for a small business. Moreover, top management should be cautious about delegating responsibilities to line managers. Not all employees will be successful in this new environment, and without procedures for monitoring and control, significant learning may be necessary as employees move into this environment.     

New governance for a new era: issues and challenges for integrating systems

In this first part of a two-part column, Dr. Ruffin introduces seven key factors that will govern the operations of integrated systems. It is important to understand, he says, that, in the movement from a fee-for-service payment mechanism, in which the various elements of the health care field bill for their services independently and according to rules designed for their benefit, to an intregrated system, in which such independence can only lead to confusion in information systems, very substantial changes will be required in the governance of our health care institutions and organizations. In the second part of the column, Dr. Ruffin will elaborate on the seven factors that must be considered in the transition.