Hospital-physician relations: overcoming barriers to cooperation.

In the September-October 1986 issue of Physician Executive, we discussed the application of strategic business units (SBUs) to health care. SBUs are those corporate entities that market similar products to one or more target populations with similar characteristics. Examples of SBUs in health care are obstetrics, cardiology, orthopedics, etc. When the services within each SBU are linked together, they might resemble a vertically integrated health care system. In the case of obstetrics, a woman may have contact with physicians, a hospital, home care nurses, house-cleaning services, birthing teachers, and maternity clothing boutiques. Each of these are products/services within the SBU of obstetrics. Strategy development by SBU implies an external focus on the marketplace in terms of the specific mission of the SBU (clinical specialty). It also implies responding to the needs of consumers for whom the historical and present divisiveness between hospitals and physicians is immaterial and irrelevant. In this article, we will focus on ways to stabilize the relationship between hospitals and physicians within an SBU context in order to compete more successfully as a team in today's health care environment.     

Important considerations in using indicators to profile providers

The demand is accelerating for information about the clinical performance of providers. In the more competitive and value-sensitive marketplace that is already developing, purchasers (consumers, employers, and insurers) of health care services will require more information to better assess the relative value of providers' (professional and hospital) services. The cornerstone of a wise, value-based strategy in selecting health care services is careful assessment of each provider's performance based on detailed, quantitative data in the form of clinical indicators. The use of indicators to profile the comparative performances of providers allows purchasers to compare as well as to influence provider performance.     

The protocol solution: a mildly acidic commentary

Protocols have captured the imagination of American's health care guru's. These self-proclaimed experts promise decreases in health care expenses of up to 25 percent if protocols for the appropriate use of expensive procedures are adopted throughout the country. With the establishment of several proprietary protocol companies and the push to develop national clinical guidelines, protocols have appeared on the health care scene with a vengeance. However, protocols will have dramatically different effects, depending on how and where they are implemented. This article will concentrate on the challenges of implementing protocols in a single health care institution, typically a hospital or a managed care institution.     

The Role of Clinical and Process Quality in Achieving Patient Satisfaction in Hospitals

Managers constantly struggle with where to allocate their resources and efforts in managing the complex service delivery system called a hospital. In the broadest sense, their decisions and actions focus on two important aspects of health care—clinical or technical medical care that emphasizes “what” the patient receives and process performance that emphasizes “how” health care services are delivered to patients. Here, we investigate the role of leadership, clinical quality, and process quality on patient satisfaction. A causal model is hypothesized and evaluated using structural equation modeling for a sample of 202 U.S. hospitals. Statistical results support the idea that leadership is a good exogenous construct and that clinical and process quality are good intermediate outcomes in determining patient satisfaction. Statistical results also suggest that hospital leadership has more influence on process quality than on clinical quality, which is predominantly the doctors' domain. Other results are discussed, such as that hospital managers must be mindful of the fact that process quality is at least as important as clinical quality in predicting patient satisfaction. The article concludes by proposing areas for future research.     

Clinical reengineering. A benchmark strategy

The health care provider marketplace continues to undergo dramatic changes with the advent of hospital mergers, acquisitions, and physician and hospital alliances. In this era of managed care, cost containment is still vital to a hospital's success, but many stakeholders--patients, employers, and physicians--are determined that quality of care also remain paramount. How can hospitals reduce their expenses and maintain a quality focus? The answer lies in a successful clinical reengineering initiative. One progressive model of clinical reengineering is presented, as well as examples of initiatives at three health care institutions. Initial results of clinical redesign programs have been dramatic and encouraging, with documented evidence of simultaneous cost savings and improved patient care.     

Design requirements for health care production control systems

This paper addresses the issue of determining design requirements for production control in health care organizations, with a restriction to the internal production control of hospitals. Hospital management has limited possibilities to control hospital production, as hospital production processes are driven by medical specialists who, however, do not manage that process. We consider therefore the hospital as a virtual organization, consisting of a number of relatively independent businesses in a common framework. Each business unit functions as a focused factory for a range of more or less homogeneous products. Production control principles can be applied to each of these businesses, but not to the system as a whole. A number of elements from classical production control theory can be also applied to health care, i.e. the use of decoupling points, the bottleneck-oriented approach, and the operational control between production and market. However, important factors that need to be considered in health production control are that often specifications on quality are not available at the start of the process, and that there is strong interaction between the patient and the process. Our conclusion is that a dedicated framework for approaching hospital production control is necessary. The specific characteristics of hospital care and its state of production control development are the main arguments for this dedicated framework.     

Value-based health care. Part I: Physicians reestablishing clinical autonomy

Clinical decision-making was once the sole purview of physicians, but no longer. Medical judgment has been usurped by third parties in the name of cost control. To reestablish this rightful authority, physicians must organize to assume the financial risks for their patients' health, using objective, clinical information to deliver superior quality outcomes. To successfully manage their patients' clinical and financial risks, physicians need to: (1) establish a structure independent of the hospital medical staff for outpatient contracting; (2) secure a capital partner that supports their independent, clinical decision-making; and (3) be leaders in acquiring and effectively using clinical information that accurately risk-adjusts and integrates both inpatient and outpatient data for all episodes of care. Physicians who acquire these skills will secure premium contracts from purchasers who are demanding value-based health care delivery.     

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.     

Physician-sponsored networks. Will physicians take back medicine?

Until about the late 1980s, American physicians and their allies, hospitals and the health care manufacturing industries, dominated all facets of the health system--the clinical, the economic, and the political. The bulk of these providers' revenue flowed to them from a highly fragmented insurance system whose governing principle was to provide each insured patient free choice of doctor and hospital. Two distinct, concurrent shifts threaten to erode the medical profession's traditional dominance. The first is a rapid, general shift of control from the supply side of the health sector to its demand side. The second is a shift away from government control, over which organized medicine held much sway in the past, toward private regulators--the executives of the managed care industry. Is the trend towards greater dependence of practicing physicians on non-physician executives inevitable, or can physicians retain--and, in part, regain--their hitherto autonomous position in the health system?     

A Hybrid Methodology for Modeling Risk of Adverse Events in Complex Health‐Care Settings

In spite of increased attention to quality and efforts to provide safe medical care, adverse events (AEs) are still frequent in clinical practice. Reports from various sources indicate that a substantial number of hospitalized patients suffer treatment‐caused injuries while in the hospital. While risk cannot be entirely eliminated from health‐care activities, an important goal is to develop effective and durable mitigation strategies to render the system “safer.” In order to do this, though, we must develop models that comprehensively and realistically characterize the risk. In the health‐care domain, this can be extremely challenging due to the wide variability in the way that health‐care processes and interventions are executed and also due to the dynamic nature of risk in this particular domain. In this study, we have developed a generic methodology for evaluating dynamic changes in AE risk in acute care hospitals as a function of organizational and nonorganizational factors, using a combination of modeling formalisms. First, a system dynamics (SD) framework is used to demonstrate how organizational‐level and policy‐level contributions to risk evolve over time, and how policies and decisions may affect the general system‐level contribution to AE risk. It also captures the feedback of organizational factors and decisions over time and the nonlinearities in these feedback effects. SD is a popular approach to understanding the behavior of complex social and economic systems. It is a simulation‐based, differential equation modeling tool that is widely used in situations where the formal model is complex and an analytical solution is very difficult to obtain. Second, a Bayesian belief network (BBN) framework is used to represent patient‐level factors and also physician‐level decisions and factors in the management of an individual patient, which contribute to the risk of hospital‐acquired AE. BBNs are networks of probabilities that can capture probabilistic relations between variables and contain historical information about their relationship, and are powerful tools for modeling causes and effects in many domains. The model is intended to support hospital decisions with regard to staffing, length of stay, and investments in safety, which evolve dynamically over time. The methodology has been applied in modeling the two types of common AEs: pressure ulcers and vascular‐catheter‐associated infection, and the models have been validated with eight years of clinical data and use of expert opinion.     

Resolving and avoiding conflict with the professional staff

The professional staff perspective radically diverges from that of management. Whereas the professional staff sees the hospital in terms of its providing quality health care to each individual patient, hospital executives see the hospital in terms of its financial and systemwide performance. Unless these divergent perspectives are effectively integrated to solve problems and formulate hospital policies, chronic conflict between hospital management and the professional staff is inevitable.     

Management education for medical students.

There is little doubt that the economics, management, and delivery of health care in the United States are currently in an unprecedented state of flux. Prospective payment, cost containment, and corporatization of health care delivery are rapidly replacing retrospective fee-for-service reimbursement and unmanaged provider practice patterns. Though ultimately certain to affect significantly physicians now in training, these changes have been afforded little attention in the undergraduate medical curriculum. At Hahnemann University, this is no longer the case. "Management Education for Medical Students" is an elective, intensive, eight-week experience for senior medical students. Following a thorough orientation to the workings of organizations through which health care is delivered, medical students receive both didactic and project-oriented instruction in university hospital administration during the first four weeks. During the course's second half, students are offered specialized training in the part of medical management that links the clinical and the financial aspects of health care management.     

The future of American health care in the "post-reform" era

"As the debate over health care reform rages in Washington, the market is reforming itself. For any given market, it's a question of 'How soon will it hit?', not 'Will it hit?'" Health care reform and market restructuring are ushering in a new era of integrated health care. Although the future is not fully clear, there are at least three competing models for the creation of regional and statewide health systems that will integrate the financing and delivery of services to large enrolled populations of consumers: Payer-driven networks. Provider-sponsored systems. Partnership models. Whatever the future scenario, physician executives will play a larger, more dominant role. Research on integrated health systems has identified three critical success factors for future success: physician-hospital integration, clinical integration and information integration. For managed care to be successful, there must be clinical leadership. The essence of managing care is clinical efficiency, based on "critical-path" treatment protocols and real-time patient care management, supported by integrated information systems.     

Physician leadership. An emerging leadership position

Demand is growing for Vice Presidents for Medical Management. This is a new physician executive position that enhances the ability of hospitals and health systems to more fully integrate delivery of care and thus attract managed care contracts. Located at a hospital, a health system's headquarters, or at a hospital's MSO, this position complements the traditional role of a hospital Vice President for Medical Affairs (or Medical Director), as well as the role generally played by the Medical Director in a managed care organization, linking them via a continuum of responsibilities. Compensation and prospects are high for qualified candidates.     

Population health--a new discipline

A new discipline--population health--has emerged with the potential to profoundly impact the U.S. health care system. Multiple forces stimulating the new population health concept include: (1) the increasing dominance of managed care and critical scrutiny of its development; (2) the continued refinement of clinical effectiveness and outcomes assessment research; (3) increasing public policy emphasis on cost-effectiveness accountability for health care services; and (4) a new focus on the importance of collaboration between the medicine and public health enterprises in this country. The need for sophisticated analysis of population health determinants has never been greater in history. New programs, like the University of Wisconsin-Madison's interdisciplinary Graduate Program in Population Health, address the need for analysis, dissemination, and application of information about the many factors affecting the health of populations.     

The importance of data warehouses for physician executives

Soon, most physicians will begin to learn about data warehouses and clinical and financial data about their patients stored in them. What is a data warehouse? Why are we seeing their emergence in health care only now? How does a hospital, or group practice, or health plan acquire or create a data warehouse? Who should be responsible for it, and what sort of training is needed by those in charge of using it for the edification of the sponsoring organization? I'll try to answer these questions in this article.     

Examining Links Between Sign-Out Reporting During Shift Changeovers and Patient Management Risks

This article reports on a qualitative study that investigated how various risk factors associated with the process of sign-out reporting across shifts in critical care hospital environments could lead to flawed communication and thus to increased risk of poor patient outcomes. The study was performed in two critical care hospital units: the pediatric intensive care unit (PICU) and the postanesthesia care unit (PACU). We collected data from observations of eight nurses and four resident physicians in the PICU and four nurses and four resident physicians in the PACU giving sign-out reports during their shift changes. In addition, we conducted semi-structured interviews with a separate sample of medical providers consisting of nurse managers, attending physicians, nurses, and residents from each of these two units. The issues that were addressed in these interviews included how various methods of conducting sign-outs and factors such as personality and experience could impact the effectiveness of communication during sign-out reporting. We also collected data from these medical providers on how failures in communication during sign-out reporting could lead to potentially adverse patient outcomes. The article concludes with the presentation of a modeling framework that demonstrates how the combined influences of risk factors can generate a particularly important type of failure mode in communication and how interventions can be targeted to serve as barriers to such events. A number of recommendations intended for reducing risks associated with the communication of sign-out reports are also presented.     

Work satisfaction, health, and stress: A study of Dutch nurses

A study was conducted to compare nurses' work satisfaction and feelings of health and stress in five different nursing departments: a cardiac care unit and a general surgical ward in a general hospital; and an admissions department, a short-stay department, and a long-stay department in a psychiatric hospital. One hundred nurses took part in the study: the instruments used were questionnaires and structured interviews. The main results showed that:

(1) nurses in the cardiac care unit had the most positive satisfaction scores

(2) nurses in the general surgical ward had the most positive scores on the health and stress variables

(3) feelings of dissatisfaction and stress were most prominent in the short-stay department and, to a lesser extent, in the long-stay department.

The findings are interpreted in terms of the different work situations and die implications for hospital management are discussed.

Dr J. A. Landeweerd graduated in industrial and organizational psychology in 1968 (PhD in 1978). He has worked at Eindhoven University of Technology (Department of Industrial Engineering) and now holds a position as senior lecturer at Limburg University (Department of Health Sciences), where he is project-leader for a number of research projects on the relationships between work and health.

Nicolle Boumans, MA, graduated in health sciences in 1985 (specialization: nursing science) and is now a research assistant. She is working on a PhD thesis concerned with the relationship between task characteristics of nurses and their reaction in terms of job satisfaction, health and stress.     

Greening the health care supply chain: Triggers of change,models for success

A historic agreement signed in July 1998 between the American Hospital Association (AHA) and the U.S. Environmental Protection Agency (EPA) signals changes in waste management in the health care industry. The agreement, which calls for a fifty percent reduction of hospital waste by 2010, will not only have an impact on hospital facility managers, but throughout the entire healthcare supply chain. As this article argues, improving the environmental impact of the health care industry should start with the health care delivery institutions themselves. The health care industry has a long way to go in addressing its environmental impacts, compared to the energy and chemical industries, for example. One reason is that these industries are raising their suppliers' environmental performance. Health care delivery institutions can effectively pull environmental performance requirements through the entire supply chain as well. This can be accomplished by examining supply chain strategies of leading industries and firms and considering the role of environmental management systems such as a ISO 14001 throughout the entire chain.