Quality versus variance: a plea for a different focus and terminology

Much has been written about quality assurance in medical practice over the past 15 years. Medicine suddenly found itself trying to design systems that ensured that medicine was being practiced according to standards of quality when it had neither a definition of its product nor defined standards of practice. Consequently, early quality assurance programs focused primarily on documentation of patient care. As the process matured, it evolved to generic screens, with tolerances and outliers. The theory was that the quality of medical care was enhanced by physicians who practiced within often artificially established norms and was diminished by physicians who practiced outside those same norms. It was much like saying that the quality of manufacturing a new car could be improved by reducing all systems down to one of closely standardizing, observing, and documenting how each individual assembly worker put on a lock nut and then holding each worker independently accountable for the final quality of the care. Physicians felt they were being held responsible for conforming to a rigid set of poorly designed and retrospectively applied standards. Moreover, they were held accountable for applying those standards to all practice situations. Understandably, physicians felt at the mercy of nonphysician quality assurance "detectives" in hospitals and became increasingly suspicious of nurses and administrators, who were perceived as abusing the system at the expense of the physicians. Because of these inadequacies of the earlier quality assurance programs, paranoia among physicians about the quality assurance process remains rampant today. The use of blind outcome scores and practice patterns in credentialing and the reporting of these data to databanks have reinforced the paranoia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of medical practice structure on resource use

The drive to national health care reform has made a central issue of variations among physicians in the use of resources to treat similar cases. While much research exists on this issue, little of it concentrates on the impact of practice structure on resource use. In this column, the author comments on that research. This column is intended as a point of ongoing analysis of health services research of importance to physician executives. The column is edited by John Kralewski, PhD, who heads the Institute for Health Services Research at the University of Minnesota.     

Linking Electronic Medical Records Use to Physicians’ Performance: A Contextual Analysis

Electronic Medical Records (EMR) studies have broadly tested EMR use and outcomes, producing mixed and inconclusive results. This study carefully considers the healthcare delivery context and examines relevant mediating variables. We consider key characteristics of: (i) interdependence in healthcare delivery processes, (ii) physician autonomy, and (iii) the trend of hospital employment of physicians, and draw on theoretical perspectives in coordination, shared values, and agency to explain how the use of EMR can improve physicians’ performance. In order to examine the effects of physician employment on work practices in the hospital, we collected 583 data points from 302 hospitals in 47 states in the USA to test two models: one for employed and another for nonemployed physicians. Results show that information sharing and shared values among healthcare delivery professionals fully mediate the relationship between EMR use and physicians’ performance. Next, physician employment determines which mediating variable constitutes the pathway from EMR use to physicians’ performance. Finally, we highlight the impact of shared values between the hospital and physicians in enhancing information sharing and physicians’ performance, extending studies of these behaviors among network partners in industrial settings. Overall, our study shows that EMR use should be complemented by processual (information sharing), social (shared values), and structural (physician employment) mechanisms to yield positive effects on physicians’ performance.     

Concern About HIV and AIDS Among Older People in the Slums of Nairobi,Kenya

The article explores the way that social networks and personal experiences affect perceived HIV‐related concerns among people aged 50 years or older living in a low resource neighborhood with high HIV prevalence in Nairobi, Kenya. Multiple logistic regression is used to model the association between the reporting of an HIV‐related concern and individual‐level characteristics, personal experiences, and social interaction. The main concerns regarding HIV reported by older people in the study included caring for orphaned children (65%), caring for people with AIDS (48%), and losing material and social support from adult children (36%). Interestingly, 38% of respondents voiced concerns about HIV infection among older people. Respondents who had been individually affected by HIV and AIDS, who were part of a wide social network, or who participated in community activities were frequently more likely to report a concern. The findings highlight the significance of the role of social interaction and social networks in the diffusion of information and knowledge. These findings have implications for HIV and AIDS policy and programs, highlighting the potential for social networks and community‐level interventions to educate and increase awareness about HIV and AIDS among older people. Community leaders can make good peer educators and communication agents for HIV/AIDS campaigns. Additionally, the recognized high level of personal vulnerability to HIV infection among older people suggests the need for targeted sexual behavior change programs among this often neglected group.     

Locum tenens solve staffing problems.

The use of locum tenens physicians (physicians who work temporary assignments) began decades ago when primary care physicians arranged coverage for their private practices while on vacation. Today, the placement of locum tenens physicians has evolved into a national business. The reason for the increase in the use of locum tenens physicians is because of the benefits they can offer. They can prevent a hospital, HMO, clinic, or physician practice from losing market share due to a gap in medical coverage.     

Physician credentialing. A centralized verification system

The current system for credentialing physicians in the U.S. is staggeringly redundant, prone to error, and expensive. The process for establishing a recent graduate's practice can involve an average of five applications to have privileges at several hospitals and HMOs. A centralized verification system needs to be developed to streamline this process. The amount of information that would have to be stored for all physicians in the country would be immense. However, the technology currently exists to store such information on a much grander scale. Credit unions, banks, and insurance companies utilize such computer systems effectively and with reasonable confidentiality.     

基于创新合作网络的产业集群知识扩散研究

创新合作网络是产业集群内部主体为适应创新复杂性的一种自组织涌现,创新合作网络结构决定了网络功能并进而影响发生于网络上的集群知识扩散过程。建立基于创新合作网络的知识扩散模型,在具有不同拓扑结构特征的规则网络、随机网络、小世界网络和无标度网络上,运用仿真方法研究集群知识扩散规律。将知识扩散效率与创新合作关系距离相联系,考虑知识的全局扩散效应。研究结果表明,具有无标度特征的创新合作网络能最大限度地提升集群知识扩散深度、知识扩散速度、整体知识水平增长效率以及具有最高的知识资源配置效率,创新合作网络中存在空间聚集的集群主体间倾向于具有相近的知识水平。最后给出促进最优创新合作网络安排的相关政策建议。     

Supply Network Structure,Visibility, and Risk Diffusion: A Computational Approach

Understanding and managing supply chain risks is a critical functional competency for today's global enterprises. A lack of this competency can have significant negative outcomes, including costly production and delivery delays, loss of future sales, and a tarnished corporate image. The ability to identify and mitigate risks, however, is complicated as supply chains are becoming increasingly global, complex, and interconnected. Drawing on the complex systems and epidemiology literature, and using a computational modeling and network analysis approach, we examine the impact of global supply network structure on risk diffusion and supply network health and demonstrate the importance of supply network visibility. Our results show a significant association between network structure and both risk diffusion and supply network health. In particular, our results indicate that small‐world supply network topologies consistently outperform supply networks with scale‐free characteristics. Theoretically, our study contributes to our understanding of risk management and supply networks as complex networked systems using a computational approach. Managerially, our study illustrates how decision makers can benefit from a network analytic approach to develop a more holistic understanding of system‐wide risk diffusion and to guide network governance policies for more favorable health level outcomes. The article concludes by highlighting the main findings and discussing possibilities of future research directions.     

高技术企业联盟知识扩散研究基于小世界网络的视角

知识通过网络可以加快扩散.作者基于NW小世界网络视角,构建高技术企业联盟知识扩散模型,揭示联盟的知识扩散特性,并运用MATLAB软件进行模拟仿真.研究发现,减小网络的特征路径长度、增大网络的集聚系数和提高成员间的知识交流频率是促进高技术企业联盟知识扩散、提高创新效率、加快知识创新的有效途径.     

Improving Computer Training Effectiveness for Decision Technologies: Behavior Modeling and Retention Enhancement*

Managers and analysts increasingly need to master the hands‐on use of computer‐based decision technologies including spreadsheet models. Effective training can prevent the lack of skill from impeding potential effectiveness gains from decision technologies. Among the wide variety of software training approaches in use today, recent research indicates that techniques based on behavior modeling, which consists of computer skill demonstration and hands‐on practice, are among the most effective for achieving positive training outcomes. The present research examines whether the established behavior‐modeling approach to software training can be improved by adding a retention enhancement intervention as a substitute for, or complement to, hands‐on practice. One hundred and eleven trainees were randomly assigned to one of three versions of a training program for spreadsheets: retention enhancement only, practice only, and retention enhancement plus practice. Results obtained while controlling for total training time indicate that a combination of retention enhancement and practice led to significantly better cognitive learning than practice alone. The initial difference in cognitive achievement was still evident one week after training. Implications for future computer training research and practice are discussed.     

集聚情景下网络惯例对绿色供应链异质性知识共享的影响——以生态工业园为例

产业集聚情景下的绿色供应链呈现显著的网络化特征，使得成员间的绿色知识流动和共享过程也有其特殊性。文章基于集聚情景考察绿色供应链网络惯例创建的逻辑以及对绿色知识共享的作用机制，构建绿色供应链的知识异质性—网络惯例—知识共享的概念模型，多维度定量剖析了网络惯例对异质性知识共享的影响。选取我国国家生态工业园460份问卷数据对其进行实证检验和仿真模拟，结论表明：绿色供应链成员之间的异质性绿色知识决定联盟绿色合作过程中能否建立起稳定可靠的网络惯例，其中，绿色异质性知识的稀缺性与不可模仿性对网络惯例的建立正向影响较大。集聚情景正向调节绿色供应链异质性知识—网络惯例(规范认同)—知识共享的关系链。为此，应充分发挥集聚的知识溢出和扩散效应，将绿色供应链平台嵌入到产业集群中，积极探索产业集聚融合下的绿色供应链异质性知识管理模式。     

Computer Use and Employment Status of Older Workers — An Analysis Based on Individual Data

Abstract. This paper analyses the determinants of computer use by male employees and estimates the impact of computer use on the employment status for older workers, based on individual data from the German Socio‐Economic Panel. In line with previous research on the diffusion of new technologies, a strong and negative relationship between the age of workers and computer use is found. The correlation of educational level and occupational status on computer use is significantly positive. However, the estimated impact of computer use on the change in employment status of older workers becomes insignificant when controlling for individual and firm‐specific characteristics.     

Work-related psychosocial,physical and individual factors associated with musculoskeletal symptoms in computer users

The aim of this study was to study associations between psychosocial, physical and individual factors, and musculoskeletal symptoms in the neck, shoulder and hand/wrist regions of computer users. Questionnaires were distributed to 5033 employees in 11 Danish companies; these employees all used computers for at least some of their work time. The response rate was 69% ( n = 3475). The analyses were based on employees working 32-41 h/week ( n = 2579). Symptomatic respondents reported symptoms for at least 8 days within the previous year. Multiple logistic regression analyses were used. Gender (female), age and duration of employment in the same job were associated with an increased prevalence of symptoms. High quantitative job demands and low possibilities for development at work were predictors of neck and hand/wrist symptoms. A high degree of repetitiveness and disturbing reflections on the computer screen were associated with symptoms in all three body regions. Repetitive movements were defined as the same finger, hand or arm movements performed many times per minute for at least 75% of their work time. Repetitiveness was the only factor that could partly explain associations between symptoms and duration of computer use, i.e. respondents who used the computer almost all the time at work reported more repetitive movements than those who used it less. Thus, long hours of computer use may be associated with musculoskeletal symptoms, due to physical factors such as repetitive movements, whereas psychosocial factors appeared to be associated with the symptoms independently of the duration of computer use.     

Work-related psychosocial, physical and individual factors associated with musculoskeletal symptoms in computer users

The aim of this study was to study associations between psychosocial, physical and individual factors, and musculoskeletal symptoms in the neck, shoulder and hand/wrist regions of computer users. Questionnaires were distributed to 5033 employees in 11 Danish companies; these employees all used computers for at least some of their work time. The response rate was 69% ( n = 3475). The analyses were based on employees working 32-41 h/week ( n = 2579). Symptomatic respondents reported symptoms for at least 8 days within the previous year. Multiple logistic regression analyses were used. Gender (female), age and duration of employment in the same job were associated with an increased prevalence of symptoms. High quantitative job demands and low possibilities for development at work were predictors of neck and hand/wrist symptoms. A high degree of repetitiveness and disturbing reflections on the computer screen were associated with symptoms in all three body regions. Repetitive movements were defined as the same finger, hand or arm movements performed many times per minute for at least 75% of their work time. Repetitiveness was the only factor that could partly explain associations between symptoms and duration of computer use, i.e. respondents who used the computer almost all the time at work reported more repetitive movements than those who used it less. Thus, long hours of computer use may be associated with musculoskeletal symptoms, due to physical factors such as repetitive movements, whereas psychosocial factors appeared to be associated with the symptoms independently of the duration of computer use.     

A rational approach to career change

Recently, the number of physicians who have been interested in alternative careers has vastly increased. Many physicians express dissatisfaction with clinical practice, but they are uncertain about which nonclinical options are appropriate for them. Pursuing a different career after many years of studying and practicing medicine can seem like an overwhelming task. In this article, the author briefly outlines a decision-making process that can be used in analyzing career options and suggests some careers that have provided challenging opportunities for physicians.     

The medical practice as business organization

Medical practices historically have not been examined in terms of their organizational structures and of the appropriateness of their structures for survival as business entities. In this paper, we propose a model for the typical medical practice and discuss its fit with current organizational theory. It is apparent that the medical practice organization does not fit with the demands of a rapidly changing and complex environment. To survive and grow, the medical practice organization must align itself with others that have an interest and stake in the health care system, develop teamwork among physicians, bridge the gap between physicians and others in the organization, and recognize that the work done in the organization depends on other components of the organization.     

企业信用内生网络模型及其演化研究

本文考虑上游企业和下游企业两个部门，通过构建企业内生网络模型研究企业间信用关联内在形成机制及其演化特征。通过对内生网络模型仿真研究，结果表明本文构建的模型重现了现实企业系统存在的一些特征：企业信用网络度分布服从幂律分布，该网络具有无标度特征；较长的合并周期则能更好地反映企业间信用关系，且随着合并周期变大，网络密度也显著增大；企业资产规模分布具有幂律尾部特征，企业资产增长率随时间演化逐渐呈收敛状，且其概率分布近似于正态分布。     

Get real: what will draw physicians to the Web?

What are physicians waiting for? What will it take to stimulate widespread adoption of Internet medical systems? How can health care leaders and physicians help the technology innovators and the executives of technology firms understand the components necessary to assure physician acceptance and utilization of new tools? (1) Don't underestimate the personal nature of a physician's practice. It really isn't a "business." (2) Most physicians are not Luddites; they are just extremely pragmatic and practical. (3) For the majority of physicians to adopt a new technology in their private office practice, it must address three major issues: money, hassle, and patient care. There are many obstacles to adopting the new technologies that are the result of physician training and expectations and the current models of payment and revenue generation. Some technological innovations are presented to physicians without sufficient respect for their knowledge of how medical practices really work. The benefits promised often don't match with the needs structure of the physicians. As a consequence, the cycle of diffusion of these new systems is extended and delayed.     

Is leadership born or made?

Is leadership born or made? By profiling three colleagues who made the transition from clinician to top-flight executive in a health care organization, the author provides case studies from which to discuss leadership issues. An evolutionary pattern has developed with respect to physicians changing careers: The first model was the medical director, followed by the vice president for medical affairs, and finally the move to managing the health care system, group practice, or managed care organization. Are physician executives fundamentally different from clinicians in terms of leadership characteristics? What are the essential qualities needed to lead health care organizations? These questions are explored in-depth.     

组织网络隐性知识扩散及学习策略分析

知识主要以显性知识和隐性知识两种方式存在,隐性知识是组织获得竞争优势的主要源泉.隐性知识为组织个体所拥有,这种私有性的特征使其在组织内部的扩散需要通过组织个体之间的交互才能完成.组织网络连接强度对扩散具有影响,可利用具有边权重的组织网络研究隐性知识的扩散行为.在分析隐性知识和相关扩散特点的基础上,基于组织成员之间的关系网络和小世界网络模型,建立组织网络上的知识扩散模型.根据认识论的观点,提出个体3种知识学习策略,结合知识扩散模型进行计算仿真实验.仿真结果显示,综合考虑关系和知识差别的知识学习策略最有效,不考虑连接强度下的各种策略都具有较快的知识学习速率,并且连接强度对组织内隐性知识扩散具有明显的作用.