The physician exodus from hospitals

Physicians are spending increasingly less of their work week in the hospital. This is true of surgeons because they are performing more ambulatory surgery, often off the hospital premises, and for primary care physicians because they are delegating hospital care of their patients to others. What are the effects of this physician exodus on hospitals, patients, physicians, and medical education? Some of these consequences are explored, from disruptions in the continuity of care, to increase in practice productivity, to preparing undergraduates for the realities of medical practice.     

The implications of practice guidelines for physician medical malpractice liability

Medical practice guidelines are increasingly coming into use, and as more and more physicians are presented with guidelines to follow in the delivery of health care, the question arises of whether these guidelines will become instruments for imposing greater medical malpractice liability on physicians. This column will briefly describe what guidelines are, how they are developed, and how they have been and may be used in litigation against physicians, hospitals, and other health care institutions. As hospitals and managed care organizations continue to implement guidelines, the role these guidelines play in malpractice cases can be expected to increase. It appears, however, that, although guidelines will contribute to the establishment of the standard of care by which a physician's actions will be measured, they are not likely to become the standard that all physician treatment decisions must meet.     

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.     

Physician executives: where they are and what they do

As hospital operations become increasingly complex, so does the institution's management and organizational structure. Physician executives with titles of medical director, vice president for medical affairs, medical administrator, chief of staff, medical staff president, etc., are playing more important roles than ever before. This article will briefly review some recent literature describing physician executive profiles. The results from a survey of ten university teaching hospitals are also presented as supplementary information regarding current staffing models. Finally, several physician executive staffing-related issues will be discussed in light of the literature and the survey results.     

Utilization management in Alberta's new funding environment

Although physicians have the greatest influence on the resource utilization of hospital patients, Canadian hospitals have not been too successful in bringing physicians into the resource planning and decision-making processes. This is because most hospitals have been unable to provide the information needed by physicians to participate in resource management in a meaningful way. With the introduction of a new system in the Canadian Province of Alberta that fundamentally changes the way hospitals are funded, it has become even more important to involve medical staffs in the utilization management process. This article describes the new funding system and highlights some of the ways in which Wetaskiwin Health Care Centre has leveraged information technology to support the utilization management process in this new environment.     

考虑交通时间与设备转换时间的跨区域就医调度优化问题

在资源共享时代背景下,跨区域就医可以很好地解决患者日益增长的就医需求与医疗资源紧张的矛盾。本论文以医疗联盟为研究对象,在关键医疗资源共享的前提下,通过患者跨区域就医实现就医诊断延误最小化,以满足患者就医需求。本研究同时考虑了患者跨区域交通时间与基于患者诊断类型的设备转换时间,以最小化患者就医总延迟为目标,分配患者就诊医院及优化患者就诊/检查顺序。针对该问题,论文首次提出以最早交货期原则（EDD rule）为基础,以患者再分配为主导的EDD-ReAss1和EDD-ReAss2启发式算法,结合局部搜索算法以进一步提高就医调度方案的质量,缩短患者诊断/检查等待时间。实验结果表明,新启发式算法EDD-ReAss1和EDD-ReAss2算法性能显著好于EDD,SPT和LPT等调度规则;在较短运算时间内Swap局部搜索算法性能最优。     

Benefits of Surgical Smoothing and Spare Capacity: An Econometric Analysis of Patient Flow

In this study, we examine the hospital's ability to admit patients from its emergency department. From a medical perspective, the number of patients being admitted should depend solely on the patients’ clinical conditions. Using a large‐scale econometric study that includes detailed operational and clinical data on all cardiac patient encounters from a set of 128 hospitals over a period of four years, we show that this is not the case. In particular, we find that independent of their medical condition, many emergency patients are denied hospital admission because of a lack of inpatient beds. Our analysis suggests that having one more inpatient bed at the start of a day can increase the likelihood of an emergency room patient admission by around 3% on average. We examine two policies – active discharge and demand smoothing – that can help hospitals improve patient access. We find that some hospitals actively discharge inpatients when beds become scarce; hospitals that follow such an active discharge protocol are, on average, able to admit more patients. We also investigate to what extent the hospital's ability to smooth its surgical schedule impacts hospital admissions. Hospitals tend to schedule their elective patients early in the week (Mondays and Tuesdays), and discharge them by the weekend in order to minimize weekend staffing, effectively maximizing bed occupancy during the middle of the week. This “weekend effect” artificially induces variability, and reduces effective system capacity. We find that by scheduling patients more uniformly over the week, hospitals can dramatically increase patient access, obviating the need for active discharges or additional capacity investment. Our analysis quantifies these effects, and can help hospitals make effective capacity management decisions in order to improve patient flow.     

Hospital medical director. Documenting roles and responsibilities

Establishing the position of medical director for a hospital entails making a clear exposition of the role of the medical director in relation to the board, the basic administrative structure, and the medical staff. The responsibilities assigned to the medical director in one hospital may differ in more than a minimal manner from those in another institution, and the nature of these relationships may also vary because hospitals differ in their traditions, internal power relationships, and functions. Because of these differences, the need to be precise about roles and responsibilities becomes even more obvious.     

CAN WE INFER HOSPITAL QUALITY FROM MEDICAL GRADUATES’ RESIDENCY CHOICES?

This paper uses a novel approach to infer hospital technical quality from revealed preferences over residency programs. Specifically, we use Spanish medical graduates’ residency choices made from 1995 to 2000. We start by estimating a model of medical graduates preferences that controls for hospital, proximity, specialty, and gender effects. We interpret the coefficients on the hospital dummy variables as measures of medical graduates’ preferences over hospitals. Our results show that graduates do indeed discriminate between hospitals and that their preferences correlate with hospital‐specific covariates arguably related to hospital training quality. We then show that preferences from medical graduates are positively and statistically significantly correlated with risk‐adjusted hospital rankings based on five alternative outcome measures. Finally, we construct reputation scores for each hospital using news story counts in three media outlets and find that medical graduates’ preferences are especially valuable for inference of hospital technical quality of care as they do not simply reflect well known reputation.     

IT Governance Characteristics,Electronic Medical Records Sophistication,and Financial Performance in U.S. Hospitals: An Empirical Investigation

As a result of a recent federal government mandate, an increasing number of hospitals have decided to adopt electronic medical record (EMR) systems. This initiative is expected to lead toward more efficient and higher quality health care; however, little is known about governance characteristics and organizational performance for EMR adopters. Our goal is to inform theory and practice by examining hospitals with a sophisticated EMR and comparing those hospitals to similar hospitals (with a less sophisticated EMR) to understand the association between information technology (IT) governance characteristics and the implications on financial performance. Leveraging elements of the upper echelon theory, we posit that hospitals in which the chief information officer (CIO) reports to the chief executive officer, CIO turnover is low, and an IT steering committee is present are more likely to have a sophisticated EMR. We argue that EMR sophistication leads to improved financial performance. Our results underscore the importance of continuity in the CIO position on successful EMR implementations. Results also show that hospital size and financial performance are strongly associated with EMR sophistication. In addition, we find that a sophisticated EMR appears to be a fundamental element in improving hospitals’ revenue cycle management. Moreover, we find that hospitals with a sophisticated EMR appear to be more profitable. Finally, we observe that total payroll expense adjusted by total discharges drops among the sophisticated hospitals, potentially due to an increase in employee productivity. These insights can serve as a basis for tempering expectations relative to the financial impact of EMR adoption.     

Path optimization for joint distribution of medical consumables under hospital SPD supply chain mode

The distribution of medical consumables inside the hospital is an important part of the daily operation of the hospital, which directly affects the operating efficiency of the entire hospital. Under the hospital SPD supply chain mode, the medical medicinal materials distribution nodes of various departments, pharmacies and warehouses of the hospital constitute the logistics distribution network of SPD central warehouse-secondary warehouse-consumption point. Considering the influence of time, distance and carrying vehicle on the distribution route of medical consumables in the hospital, the optimal distribution model of medical consumables under the hospital SPD supply chain mode was established with the minimum distribution cost of the hospital. The corresponding GA is designed and solved by MATLAB programming software. According to the established path optimization model, the distribution path optimization of medical consumables in a hospital in Shanghai is realized. The results show that the model is in line with the actual needs of the hospital; the algorithm is validated and the convergence speed is fast; compared with the traditional distribution path of medical consumables in the hospital, It is found that the optimized hospital medical consumables joint distribution path reduces logistics costs and improves the efficiency of distribution services. This article optimizes the joint distribution route of medical consumables in hospitals, promotes the organic combination of hospital SPD supply chain model and hospital operation structure, and promotes the modernization process of Chinese hospitals.

     

Clinical practice guidelines and medical malpractice

As clinical practice guidelines become more and more prevalent, they will define the requisite "standard of care" for medical treatment and impact medical malpractice litigation. They may even replace expert testimony.     

Models for medical practice integration

Decreased physician income, increased administrative burdens, and interference with the compassionate delivery of high-quality medical care are threatening the independent practice of medicine in solo and small group practices. Many established physicians, and the hospitals with which they relate, are searching for organizational models that, by integrating some or all aspects of their practices, will preserve incomes and reduce regulatory and administrative burdens. This article will describe several "practice integration models," pointing out advantages and disadvantages to physicians in established practices. (Many of the same arguments could be made for physicians new to practice, with different emphasis). The continuum of integration models is shown in figure 1, page 19. The group practice without walls and its two submodels, the independent group practice without walls (IGWW) and the affiliated medical practice corporation (AMPC) are more recent and more effective models and will be covered in depth in the article.     

震后多目标动态应急医疗设施选址-伤员转运问题研究

地震等灾害的突发性和破坏性常导致部分伤员无法得到快速有效的救治，同时会给伤员造成一定的负面心理，影响救援效率。本文综合考虑救护车辆（救护车、直升机）和医疗设施容量的动态变化、各类伤员生存概率随时间动态变化以及伤员心理状况变化，构建了最大化伤员生存数量和最小化心理成本的震后伤员二级后送模式的医疗设施选址-伤员转运双目标动态规划模型。运用epsilon约束法有效处理双目标模型，以玉树地震后伤员后送问题为例，采用CPLEX对模型进行求解，通过分析医疗资源数量对伤员转运数量的影响，表明在伤员后送过程中，增加临时医院数量或容量与救护车数量比增加后方医院数量或容量与直升机数量更有效；考虑伤员的心理成本，为了提高伤员存活率，在灾害前期，可以通过增加救护车数量，转运更多的重伤员，而中后期提高临时医院容量，尽量优先转运轻伤员。     

HOSPITAL ADMINISTRATOR FELT NEEDS FOR INTERORGANIZATIONAL COOPERATION AND ACTUAL COOPERATIVE OUTCOMES BY THEIR HOSPITALS

This paper presents an empirical analysis of the determinants of interorganizational cooperation among hospitals. Hospital administrator felt needs for programs of interhospital cooperation and actual cooperative outcomes by their hospitals are examined. A combination of survey and archival data is used to test several research hypotheses. Results support separating the interorganizational activities of hospitals into those related to medical and those related to ancillary service areas. Felt needs to cooperate in both service areas are influenced by administrators' concerns for hospital autonomy and image in interorganizational relations. Perceived availability of cooperation partners affects felt needs to cooperate only in the area of medical services. Actual levels of cooperative activity in medical services are related to perceived manpower resource scarcity, historical levels of cooperation, and concerns for hospital image in interorganizational relations. In ancillary services, actual levels of cooperation were related to perceived financial resource scarcity, historical levels of cooperation, and perceived availability of cooperation partners. Felt needs to cooperate were not associated with actual cooperative outcomes in either service area. The results contain implications for future research into the decision processes that give rise to interorganizational relationships of cooperation.     

Primary care networks: choose your physicians wisely

As hospitals and health care systems maneuver for a position in the integrated health care delivery system, no initiative is more important than building an effective and competitive primary care network. Yet this critical initiative is fraught with potential pitfalls. In their haste to develop primary care networks, hospitals and health care systems may fail to thoroughly evaluate network participants and in turn create large, inclusive, and inefficient primary care networks that don't come close to breaking even, much less repay practice acquisition costs. In an effort to become more efficient, practitioners often find themselves in the unenviable position of "de-selecting" peers retrospectively. The author presents criteria for evaluating and selecting network physicians.     

Information technology, Part 3. The technology hierarchy

The era of the networked society--and medical care depending on networked intelligence--is dawning. Physicians need to plan for office practice information systems in common, with an eye to conveying data electronically between all the locations of care and all the providers involved in caring for defined populations of people. The shared database will become the most important asset of the collection of providers who make up the delivery system that creates it. This will be accomplished by layering technology on local and wide-area networks of group practices, hospitals, health plans, and payers and developing standards that make data accessible in the same format to all users, no matter where they are.     

Reibungsverluste an peripheren und internen Schnittstellen

Loss of energy in peripheric and internal interfaces. Considerations on the management of costs and quality in hospitals Organization development, coming from economics, now has reached the area of service societies. The counselors, who are engaged in hospitals, usually are educated in industral management and have a technical and economical view of organization. The author discusses the question, whether their strategies may fit to the organization of hospital, and he proposes to modify the common approaches of organization development. Before the ?therapy“ as the actual organization development may come to pass, a more detailed ?diagnosis“ has to be made: by an examination of the peripheric and internal interfaces, where usually an avoidable loss of energy occurs. Further more, he proposes a comprehensive management of organizational intersections.     

Ascendancy of primary care will create role intensification for physician executives

The need for physicians in management roles in the health care system has never been greater. And the years ahead will see that need broadened and intensified. To maintain their leadership role in medical affairs in hospitals and other types of health care delivery organizations, physician executives will have to envision provider organizations and systems that have not yet been conceived, let alone developed and implemented. They have to become totally open-minded and futuristic in their thinking. And they will have to help other physicians accommodate this new way of thinking if the medical profession is to continue in a leading role in health care matters. Although numerous factors will have to be anticipated and analyzed by these new physician leaders, the ascendancy of primary care in a managed health care world long dominated by the technical and technological superiority of hospital care will present a particular challenge to the physician executive.