Information technology enters the doctor's office: Part II--Six lessons about intended ... and unintended ... results

Part I of this article ("Six Design and Implementation Lessons," Physician Executive, Sept.-Oct. 1993, pp. 46-50) described an ambulatory utilization review (AUR) program designed and implemented by Metropolitan Life Insurance Company and reviewed some of the lessons learned over the past five years. Those lessons pertained to the tasks of inventing a new information technology to measure and evaluate ambulatory care and some of the practical implementation issues associated with review of 30,000 small dollar value claims per day in 19 claim offices nationwide. This article turns to the basic purpose of AUR--to review the medical necessity and appropriateness of ambulatory utilization. One lesson learned about AUR in this context is that AUR works: savings from the program outweigh costs by almost 5:1. The more important lessons, however, stem from understanding how the savings are achieved, and what some of the other unintended benefits of the program are.     

How to shape positive relationships in medical practices and hospitals

Managing workplace conflict is one of the most important, stressful, and time-consuming tasks faced by today's medical leaders. Poorly managed workplace conflict can alienate patients, demoralize staff, increase turnover, damage relationships with valued referral sources and third party carriers concerned about patient satisfaction, and lead medical practices to costly "corporate divorces." Physician executives cannot solve the problems caused by disruptive doctors simply by bolstering their own conflict management skills or by policing offenders. The larger contexts within which inappropriate workplace behavior occurs must also be assessed and addressed. The true leadership challenge is to intervene in ways that help to foster a "culture" of appropriate interpersonal dynamics throughout your organization. This requires learning to think and to intervene systematically.     

Public hospitals: an assessment and plan for the future.

We are currently living in very difficult times for most health care providers. Even though we have always known it, the fact that resources for health care are limited is now abundantly apparent to consumers, health care providers, fiscal intermediaries, government (local, state, and federal), health care planners, and policy makers. Hospitals, especially, are being severely pressured to reduce resource consumption and costs. Conditions that are difficult for nonpublic hospitals are critical for public hospitals in general and nearly fatal for rural public hospitals. Fortunately, nonpublic hospitals are beginning to realize for the first time that their future depends, to a significant degree, on a strong and financially healthy public hospital system. If the public hospital, the hospital of last resort, closes, medically indigent patients will have to be treated in nonpublic hospitals, with the resultant medical, financial, economic, political, and social consequences. Therefore, the importance of public hospitals has to be even better recognized and appreciated and these institutions actively supported in order for the private and total health care systems to be successful.     

Innovation, cultural values, and the management of change in British hospitals

This paper describes the results of a study of innovation in the management teams of 27 UK hospitals. It is argued that the content of innovations provides an accurate representation of the underlying cultural values of the management teams, and the cultural values which they seek to purvey within the wider organizational settings. The authors propose that values in action (as opposed to espoused values) are manifest in the range of innovations introduced by top management within organizations. Using a typology of organizational culture, they categorize the innovations introduced by the management teams, in order to map their underlying cultural values. The results indicate predominant orientations of hospital management teams towards rational goal and hierarchical values in the current context of health care in Britain. Internal climate and service innovations were relatively infrequent, suggesting that the hospitals were dominated by management concern for control rather than flexibility. The costs of such cultural strategies in health service settings are discussed.     

Health care trends, Part I. The promise and perils of evidence-based medicine ... panel discussion.

Numerous studies have demonstrated that there are wide variations in the way physicians manage similar patients. This suggests that an evidence-based approach could lead to better outcomes with less cost. But practicing evidence-based medicine requires new skills, such as using computerized databases and applying the rules of evidence to primary and integrative studies in the medical literature. The progress of evidence-based medicine will depend in large measure on how quickly these new skills can be developed and integrated into the practice environment. Here's how six experts see the promise and the perils of evidence-based medicine, now and in the new millennium. Part 2 of the panel discussion will explore the new provider team, which includes nurses and, more recently, pharmacists, who are collaborating with physicians to provide disease management and drugs therapy management services.     

Approximation algorithms for hard variants of the stable marriage and hospitals/residents problems

When ties and incomplete preference lists are permitted in the Stable Marriage and Hospitals/Residents problems, stable matchings can have different sizes. The problem of finding a maximum cardinality stable matching in this context is known to be NP-hard, even under very severe restrictions on the number, size and position of ties. In this paper, we describe polynomial-time 5/3-approximation algorithms for variants of these problems in which ties are on one side only and at the end of the preference lists. The particular variant is motivated by important applications in large scale centralised matching schemes. A preliminary version of this paper appeared in the Proceedings of COCOON 2007, LNCS, vol. 4598, pp. 548–558. This work was supported by EPSRC grant EP/E011993/1.     

Part 2, Conflict management. How to shape positive relationships in medical practices and hospitals

Managing workplace conflict is one of the most important, stressful, and time-consuming tasks faced by today's physician leaders. In Part 1 of this article series, the authors describe how to assess an organization's interpersonal dynamics. True change comes from interventions that help an organization to become a positive interpersonal culture, one that fosters cooperation and collaboration. Part 2 offers seven steps to solving the disruptive physician problem: (1) provide protection to complainants; (2) listen, empathize, and avoid communication triangles; (3) confront offenders with data, authority, and compassion; (4) if needed, get outside help; (5) offer workplace training and experiences that foster positive relationships; (6) follow-up; and (7) practice what you preach. The self-assessment and intervention guidelines discussed in this series of articles can help physician executive move beyond struggling with episodes of conflict to shaping stress-resilient medical organizations.     

The JCAH quality initiative: what can hospitals and physicians expect?. Interview by Emily Friedman.

In his new position at the JCAH, Ol'Leary has been shaking things up. His most talked-about move has been to initiate a broad-scale reconfiguration of the Joint Commission's approaches to evaluating quality. The principle element of this effort calls for structural and functional indicators to be augmented by clinical performance and outcome criteria. This is the first of two articles concerning Dr. O'Leary's views of the future of the Joint Commission. In this article, he discusses the new quality assurance initiative; in an article in the September-October issue of Physician Executive, his vision of the future of the JCAH, and the environment in which it will be operating, will be explored.     

Behavioural criteria of managerial and leadership effectiveness within Egyptian and British public sector hospitals: an empirical case study and multi-case/cross-nation comparative analysis

This paper reports the results of a study of managerial and leadership effectiveness carried out within an Egyptian public sector hospital in which concrete examples of ‘effective’ and ‘least effective/ineffective’ manager and managerial leader behaviour, as observed by superiors, peers and subordinates, were collected using the critical incident technique. These critical incidents were then content analyzed to identify a smaller number of discrete behavioural statements and criteria of effectiveness. The paper also reports the results of a subsequent comparative analysis of these Egyptian findings against equivalent behavioural criteria that emerged from studies in two different British NHS Trust hospitals. This latter multi-case/cross-nation study revealed high degrees of overlap, commonality, and relative generalization across all three organizations. The results lend strong empirical support to those who believe in ‘generic’ and ‘universalistic’ explanations of the nature of managerial and leadership effectiveness.