Wanted--seasoned veterans. Diamonds in the rough need not apply

Health care organizations looking for physician executives prefer seasoned veterans--doctors who have already done the job. They want job-specific experience. Most organizations do not provide training grounds and orderly career ladders for aspiring physician executives. The Permanente Medical Groups, Family Health Plans, and some very large group practices are exceptions, but, for the most part, rising medical directors in these organizations stay with them. Most hospitals are not large enough to have associate or assistant medical directors or an environment that could provide a training ground for rising physician executives. On the other hand, hospitals, larger group practices, health insurance companies, and managed care organizations provide ample opportunities for nonphysician managers to train, gain experience, and climb the ladders. How can the novice physician executive break into the world of management and begin establishing management credentials? The author provides some key steps that can lead to success.     

Shifting Concepts of Autonomy in the Hong Kong Hospital Authority

The Hong Kong Hospital Authority is the main provider of public health care services in Hong Kong. It operates 41 public hospitals, 74 general out-patient clinics and 45 specialist out-patient clinics. This article examines the reason for its establishment as a statutory body in 1990 and offers an assessment of its success in meeting the goals of the reformers. A belief that health care service delivery would be improved is largely supported by the evidence, but this may have more to do with budget and policy consistency than management autonomy and flexibility. Statutory independence, with its promise of improved efficiency, has its limits in the highly complex field of health where there are multiple players and where professional autonomy remains a key claim. In recent times, the authority has been subject to several reform attempts and, together with the SARS epidemic in 2003, these have had a significant impact on its organizational structure and practices, in particular, on its degrees of autonomy.

---

     

Building a vertical provider system

There is probably no geographic area in the United States in which the health care environment is more turbulent than that of Southern California. Long before President Clinton's proposals began serious national debate on health care reform, a massive provider-driven realignment of the system was occurring in that region of the country. Multispecialty medical groups have generally led the way and have acquired ever larger managed care populations through merger and acquisition of other groups and practices. Hospitals, hampered by large fixed capital bases, have struggled to reinvent themselves as cost-effective and primary care-friendly environments in order to be attractive to managed care physicians. Almost ignored in this reconfiguration has been the university teaching hospital. This article discusses one attempt to reconcile contractually an integrated, capitated, and managed care-oriented health care system with an academic medical center in a strategic alliance.     

Patient Hochschulmedizin

Patient university medicine. Changes of the legal framework of university hospitals in the context of the German health reform The situation of university of medicine can be compared to that of ?a servant of two masters“. Issues of performance and financing as well as legal regulations and administrative procedure have their roots in both the academic and the health system. While medical training is unthinkable without hospital practice, the ?supra-maximalist care“ produced by university hospitals is absolutely essential in the interest of public health. Out of the complexity of teaching, research and medical care grow valuable additional results but also above average costs which could reduce the competitiveness of university hospitals, once the change of financing to DRGs as a consequence of health reform is generally applied. The problem is made worse by outdated academic decision structures, by unsuitable buildings and by the lack of public funds for their structural maintenance and modernization. With this situation in mind the Federal States of Germany in the mid nineties began to search for alternative sources of investment and for a more efficient legal framework. The article explores the question which proposed solutions were subjects of discussion and why the concept of a public law institution became the favourite in the end.     

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.     

The role of the coordinator of care

Regardless of the specific outcome of the current health reform debate in Washington, it is likely that major changes to the health care system are in the offering. These changes, many of which are already in place or imminent in some locations, will have a major impact on the evolving relationships between physicians and hospitals. Most expect that these changes will accelerate the development of integrated health care delivery systems that will compete in the marketplace for a mixture of public and private health insurance dollars. In this system of "managed competition," health care dollars will flow to those systems that can ensure the best clinical outcomes while using the least economic resources. In this scenario, competing collaborative health networks that can manage the continuum of care will be central to the health care delivery system. The economic and political ties between physicians and hospitals will become more closely linked as government and private payers of health care services foster the development of these integrated, value-based health care delivery systems.     

Strategic Purchases of Bundled Products in a Health Care Supply Chain Environment*

Recent articles in the Wall Street Journal summarize the state of business practice in American hospitals by shedding light on the state of supply chain management practices and foci in today's health care supply chains. In health care, the single largest cost after labor is materials, and it has been documented that health care facilities can reduce the environmental impacts of the products and services they consume before regulatory problems arise or waste disposal costs increase by focusing on their upstream activities. Health care systems around the country consume significant quantities and varieties of products within the health delivery processes. Solving these environmental problems requires a much broader view involving collaborative efforts of professionals from different areas of health care to meet these challenges. The purchasing function bridges the gaps by providing a healthy dialogue on key environmental attributes within the health care supply chain. The concept of bundling new with refurbished products is gaining a lot of attention in the health care supply chain. This research describes a health care purchasing problem for bundling new and refurbished products of the type facing a growing number of large health care providers, and then proposes a methodology for evaluating the complex tradeoffs involved in bundling decisions for refurbished health care products. By exploiting some useful properties of the problem structure, our results provide buyers with useful insights for examining and selecting suppliers who are willing to offer bundles of new and refurbished products.     

医疗费用上涨与医德医风下降:组织架构变革角度的解释

改革开放以来,我国医疗卫生事业在快速发展过程中产生两个突出的问题:一是医疗费用增速过快;二是部分医院医德、医风下降。关于医疗费用增速过快,以往的研究主要从“成本驱动”的角度进行解释,而对医院医德、医风下降则从“环境诱导”的角度进行解释。本项研究选择6家大型国有综合医院作为案例,对医院组织架构的核心——决策权分配、业绩评估和激励政策的变革进行了考察,对变革的影响从医院与内部职工、患者和第三付费方的角度分别进行了分析,对医疗费用增长和医德医风下降从医院组织架构变革角度进行了解释。本文也对研究结论的政策意义进行了讨论。     

The impact of health care reform on group practice

Just two years ago, it would have been very difficult to imagine that reform of the health care system would today be a national domestic priority and that Congress would be considering one of the most significant and far-reaching pieces of legislation in the past 50 years. The issue is still in doubt, but it seems clear that, in this session of Congress or the next, legislation of far-reaching consequences will likely be passed. In fact, change on a widespread scale has already begun. During 1993, every state legislature except those of Nevada and Wyoming considered measures that would alter the way medical care is financed and delivered. Of the states that acted, both last year and in recent legislative sessions, eight have passed laws with the ultimate objective of ensuring access to medical care for all citizens. Government, at both the state and federal level, is clearly taking on the health care issue. The impact of reform on physicians, and thus on group practices, will be substantial. This article outlines the current course of health care reform and addresses its specific implications for the management of group practices.     

Application of Human Reliability Analysis to Nursing Errors in Hospitals

Adverse events in hospitals, such as in surgery, anesthesia, radiology, intensive care, internal medicine, and pharmacy, are of worldwide concern and it is important, therefore, to learn from such incidents. There are currently no appropriate tools based on state-of-the art models available for the analysis of large bodies of medical incident reports. In this study, a new model was developed to facilitate medical error analysis in combination with quantitative risk assessment. This model enables detection of the organizational factors that underlie medical errors, and the expedition of decision making in terms of necessary action. Furthermore, it determines medical tasks as module practices and uses a unique coding system to describe incidents. This coding system has seven vectors for error classification: patient category, working shift, module practice, linkage chain (error type, direct threat, and indirect threat), medication, severity, and potential hazard. Such mathematical formulation permitted us to derive two parameters: error rates for module practices and weights for the aforementioned seven elements. The error rate of each module practice was calculated by dividing the annual number of incident reports of each module practice by the annual number of the corresponding module practice. The weight of a given element was calculated by the summation of incident report error rates for an element of interest. This model was applied specifically to nursing practices in six hospitals over a year; 5,339 incident reports with a total of 63,294,144 module practices conducted were analyzed. Quality assurance (QA) of our model was introduced by checking the records of quantities of practices and reproducibility of analysis of medical incident reports. For both items, QA guaranteed legitimacy of our model. Error rates for all module practices were approximately of the order 10(-4) in all hospitals. Three major organizational factors were found to underlie medical errors: "violation of rules" with a weight of 826 x 10(-4), "failure of labor management" with a weight of 661 x 10(-4), and "defects in the standardization of nursing practices" with a weight of 495 x 10(-4).     

What do you have to do to become a medical director?

Medical management is a large and growing profession. The need for physicians in management roles grows unabated in hospitals, managed care organizations, group practices, and myriad other environments. But entry is not merely a matter of wishful thinking. Painstakingly assembled credentials and skills are the order of the day. The advice in this column is distilled from Medical Directors: What, Why, How, a new College monograph.     

Health care reform. Pan American Uni-Care Health Insurance Plan

Something is definitely wrong with the American health care system. Too many citizens are denied health care, and health care costs continue to rise at an uncomfortable and intolerable rate. Ensuring care for all is a paramount goal. There is no way to simultaneously cover everyone; leave the reimbursement of physicians unrestrained; ensure instantaneous access to every imaginable high-technology service; subsidize the world's costliest and least efficient health bureaucracy; and contain costs. Widespread dissatisfaction in all quarters--physicians, hospitals, third-party payers, regulators and consumers--has led to an avalanche of reform proposals. Rapidly changing social, political, and economic environments; rising fiscal pressure; and an evolving understanding of the major determinants of health have also created pressure for changes. There are some new and hopeful signs that America is facing up to the need for changes in the health care delivery system. The Pan American Uni-Care Health Plan that is described in this article may serve as a reasonable balance among these competing priorities.     

The new production theory for health care through clinical reengineering: a study of clinical guidelines--Part II

In Part I of this two-part article, in the December 1994 issue of the journal, the author discussed the manufacturing theories of Peter Drucker in terms of their applicability for the health care field. He concluded that Drucker's four principles and practices of manufacturing--statistical quality control, manufacturing accounting, modular organization, and systems approach--do have application to the health care system. Clinical guidelines, a variation on the Drucker theory, are a specific example of the manufacturing process in health. The performance to date of some guidelines and their implications for the health care reform debate are discussed in Part II of the article.     

Health‐care Nonprofits: Enhancing Governance and Public Trust

Nonprofits are a major part of the U.S. economy and they are not immune from corporate malfeasance controversies. Even Congress has expressed concern about the crisis in nonprofit governance. The nonprofit response to Congress has been a historic initiative recognizing critical challenges to nonprofit governance. In contrast to their for‐profit counterparts, nonprofits are committed to missions serving the public benefit and not to shareholder profits. Accordingly, their missions and financial resources are intrinsic to their very existence, which is built upon the public trust. That trust is rooted in fiduciary responsibility and reflected in best practices. This article traces the history of the nonprofit public trust and fiduciary standards and examines principles of Sarbanes–Oxley and other best practices as they apply to nonprofits. The authors sampled 80 health‐care nonprofit corporation web sites from eight asset classes to determine compliance with Sarbanes–Oxley and identification of fiduciary duty, ethical values, and other best practices. Among the very largest health‐care nonprofits, many comply with Sarbanes–Oxley and identify fiduciary duty, ethical values, and other best practices. However, there are substantial deficiencies in such compliance and identification among all remaining seven asset classes ranging from 99.9 million to less than 100,000. The results appear to corroborate the urgent necessity for reform articulated by the Congress and the nonprofit sector. Nonprofit governance has entered a new era where best practices must be implemented to sustain the public trust.     

From managing access to managing care: the impact of primary care on health care delivery organizations.

Professional "revenge of the nerds" is currently taking place, as managed care evolves generalist physicians into new professional prominence. Primary care physicians are finding themselves at the center of health care market reform as health plans, insurers, and other financing organizations turn to them as the key to cost control. In short supply, they are prospering financially from the demand. As the source of patients, they are gaining in prestige from specialists and hospitals who once demeaned them. But these newfound roles are only the initial steps in the transformation of the primary care practitioner. The change that the generalists are experiencing is essentially managing access to care, not truly managing care itself. There are large and crucial differences between managing access to care and actually managing care. These differences are, in many ways, a higher calling for primary care practitioners as they refocus attention on patient outcomes, which will in itself result in a lower resource utilization above and beyond the crude controlling of access. What those differences are, what new roles they require, and what impact they will have on organizations that either house or contract with primary care physicians will be the focus of this article.     

Möglichkeiten der Öffentlichkeitsarbeit für Krankenhäuser

Possibilities of public relations for hospitals While it is normal for hospitals in the USA to advertise or to do public relations, it is rather uncommon in Germany. Since hospitals in Germany are faced with rising competition and budget restrains of the public health system it seems they are recognizing more and more, that it is difficult to compete in the market without doing public relations. Therefore basic possibilities to reach certain target groups with public relations are presented. Subsequently the case of the Schlosspark-Klinik demonstrates, how it is possible to create public relations, which are strictly oriented towards the main strategy of the hospital.     

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.     

Health care's power brokers in the 21st Century. Interview by Donna Vavala

Health care has undergone turbulent change in the 20th Century. In addition to dramatic pharmaceutical and technological advances, the entire health care delivery system has been significantly improved. Through all the turmoil, hospitals have been at the center of the health care universe. But, as the 21st Century approaches, that may change, too. What will become of hospitals, which for most of this century have played a commanding role? Will managed care organizations and group practices come out on top? And, once the new power broker takes over, what will be the impact on providers, insurers, and the government, and how will their relationships to each other change? Jeff Goldsmith, PhD, President of Health Futures, Inc., Bannockburn, Ill., and health care futurist, examines tomorrow's health care delivery system and makes some eye-opening predictions.     

When push comes to shove: implementing VBAC practice guidelines

The dramatic increase in U.S. cesarean sections over the past two decades has been significantly driven by repeat C-sections. In response to this trend, clinical guidelines recommending vaginal birth after cesarean-section (VBAC) have been promulgated by national organizations. Adherence to these guidelines would reduce the number of repeat C-sections, lower the overall C-section rate, and improve both the quality and the cost of health care. While these guidelines have received professional endorsement, their implementation has been clouded by issues of patient acceptance and provider payment. To examine implementation of these guidelines by health care organizations, the authors surveyed 156 members of the American College of Physician Executives to determine their policies, practices, and attitudes toward VBAC guidelines. Those surveyed generally were medical directors in HMOs, hospitals, and other practice settings. The findings indicate that the health care organizations represented by these physician executives have not consistently implemented VBAC guideline and that they are reluctant to hold physicians, their patients, or hospitals accountable for the financial, utilization, and quality impact of the elective decision ot to pursue appropriate VBACs. We conclude that, even when widely accepted, clinical practice guidelines may be ineffective in reducing the costs or improving the quality of medical care.