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.     

My third year as chief of staff

Passing a Joint Commission survey, dealing with a sexual harassment complaint and writing a performance pay plan are just a few of the issues that a chief of staff in the VA wrestled with during his third year on the job.     

A BRIDGE FOR TWO CULTURES C. JACKSON GRAYSON,JR., CHAIRMAN,PRICE COMMISSION

C. Jackson Grayson, Jr. was the invited speaker at the President's Luncheon of the Fourth Annual Meeting of the American Institute for Decision Sciences. His remarks dwelt on the relation of his experience as a scientist and academician to the tasks he faced in his assignment with the Price Commission. Dr. Grayson is currently on leave from his post as Dean of the School of Business Administration at Southern Methodist University.     

Reinvigorating stalled CQI efforts through physician involvement

Continuous quality improvement (CQI), loosely synonymous with total quality management (TQM), was designed for the comparatively simple world of industry. Now that the gurus of CQI have attempted--originally with full support of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)--to apply the industrial CQI model to hospitals, they've noticed something: The model doesn't work, and hospital CQI programs are faltering enough to persuade the Joint Commission to scale back its CQI accreditation requirements. One major shortcoming behind the performance to date of CQI in hospitals: Physicians don't fit into the industrial model of CQI. Physicians are too important, and too many programs are stalled, to continue to implement CQI as though physicians don't exist. The techniques described here should help to reinvigorate faltering programs, giving hospital management a chance to "do it right the second time."     

When should there be liability for negligently causing psychiatric illness?

In March 1998 the Law Commission for England and Wales published the outcome of its review of the law on compensation of those who suffer psychiatric illness as a result of the negligence of another person. The report is largely, although not solely, concerned with work-related illness. It also reviews the literature on the incidenc and forms of psychiatric illness. It makes recommendations for legislation. This paper critically summarizes the findings of the Commission and concludes with some comments. It questions the appropriateness of common law litigation for these kinds of injury. It also comments on whether the Commission's recommendations will be implemented by Parliament and the likely impact of the proposed revision of the law upon the incidence of litigation.     

企业家人力资本的自我甄别与市场配置--企业家人力资本的理论模型及其涵义

以往的企业家理论主要集中在对企业家的行为特征进行研究.但是企业家理论的关键是企业家个体怎样向市场传递其企业家信息并被市场选择.张维迎博士提出的"个人财富--企业家能力"模型在此做了开拓性的研究,提出了个人财富是企业家能力信息的市场显示的原理,但在许多方面还需要讨论.本文在该模型基础上,通过引入企业家人力资本的概念,提出企业家的人力资本模型.这一模型把企业家的选择分为两个阶段企业家人力资本的积累和企业家人力资本的配置.在企业家人力资本积累过程中个体完成了企业家资格的自我甄别,其中个体的先天心理特质和制度环境起着重要作用.企业家人力资本的配置是企业家人力资本的市场甄别,即市场对个体传递的企业家人力资本信号--学历、经历与业绩、个人资本和社会资本--进行甄别,以发现"真正"企业家人力资本,并完成企业家人力资本的配置.其中个人财富只是一个重要信号,而不是唯一信号.     

How to keep the Joint Commission happy and plaintiff's attorneys frustrated

With the first minimum standard by the American College of Surgeons in 1918, the credentialing of physicians became formalized Since those days, in which a physician was basically required to be licensed and of high professional, moral, and ethical character, many requirements have been added. All have been appended for the safety and quality of care of our patients. However, liability attorneys have discovered credentialing requirements and found them a veritable gold mine for litigation. As rapidly as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) offers another standard to help us protect not only our patients but also ourselves in this litigation-bent atmosphere, attorneys engineer a way to bring suit, using the standard as if it were a requirement for prevention of negligence rather than a self-imposed goal for attainment of quality. This article presents a method of credentialing medical staff members that neutralizes the threat of antitrust actions alleging the compromising of livelihood by the denial of membership or clinical privileges. Additionally, the methodology offers maximal protection and integrity of credentialing procedures while optimizing compliance with Joint Commission standards.     

The private practitioner in hospital quality assurance

External forces continue to dictate the necessity of delivering high-quality health care along with methods of proving that the claimed quality is attained. Gone are the days when both the institution and its practitioners could answer quality questions simply by stating that they were delivering excellent health care to their patient population. The federal government, via the Health Care Financing Administration, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are mandating that institutions prove, without question, that they are delivering health care of the highest quality. The essential key to attaining these goals is cooperative private practitioners.     

Meet the mandate to measure clinical quality

The mandate for health care organizations to be accountable for quality, as well as price, is now unavoidable. The Joint Commission's ORYX project is requiring every hospital to measure clinical outcomes of a majority of its patients within the next three years. This mandate can be met best with systems of clinical outcomes measurement that provide valid, reliable risk adjustment; yield meaningful information about many different diseases and procedures; and measure more than mortality or cost--all using primarily billing data. New outcomes measurement tools with all of these capabilities are available and have already enabled quality improvement in dozens of hospitals across the U.S.     

Strategy,cross-subsidization and the “business portfolio”

Business portfolio analysis is becoming an increasingly important and indeed critical element in strategy analysis, and the problem of cross subsidization will almost certainly become an issue of some importance for managements under the influence of the new Price Commission. This article analyzes the problem of developing corporate strategy on the basis of the individual contributions which inter-dependent groups of services and products make to the company's profitability, stability and future potential.     

Reinhardt on reform. Interview by Donna Vavala

Almost since the federal government took its giant step into health care delivery and financing in 1965 with Medicare and Medicaid, the emphasis in Washington has been on reducing the costs of health care. Almost all federal health law subsequent to those two programs has been aimed at cost control, even when the titles of the bills promised a more noble purpose. The most notable exception is the law establishing end-stage renal disease coverage, but it has become a prime exacerbator of rising costs. Not even the designers of the federal programs envisioned how quickly health care costs would rise and how substantial the increases would be. The federal tab in 1993 was $280.6 billion. In 1960, it was $3 billion and in 1970 it was $17.8 billion. And overall health care costs have followed a similar curve, growing from 5.3 percent of the U.S. GDP in 1960 and 7.4 percent in 1970 to 13.8 percent in 1993. The end is not in sight. Economists are predicting growth to 18 percent of GDP by the next century. Uwe E. Reinhardt, PhD, James Madison Professor of Political Economics in the Woodrow Wilson School at Princeton University, does not believe that the "bite" will become that large, but he does expect increases to continue into the near future. In the interview recorded in this article, Professor Reinhardt assesses both the current and his predicted financial scenario for the health care field.     

王梓木：雪上飞

如果没有人们的后见之明，一些可震烁古今的大事件，原本都平淡无奇。在古代中原与边关的种群冲突中，为什么只要是农耕种群总是负多胜少？历史是势利的，甚至只敬重成则为王的那个人。当努尔哈赤以他坚强的女真族后裔一满族甲士的铁骑，让无数民族在苦难中改变了自己的走向后，后人总是试图从这段历史寻找出种群血性的真相。     

The physician executive and the future.

In summary, physician managers have a bright future. They are working on one of the most exciting professional interfaces--medicine and management. The future of medicine is both high-tech and low-tech. It will challenge all physician executives. For a few years, health care organizations will experience turbulence and stress. The name of the game for physician managers will be organizational survival. The nation will then move into an era of abundance in medical care, and the management game will switch from survival to thrival. Managers are key players in the world of tomorrow. The physician executive is a manager and therefore a key player. One of the best things about the future of the physician is that he has one.     

Equity, equity, that's our cry. Interview by Richard L. Reece.

On February 11, 1999, Richard L. Reece, MD, interviewed J.D. Kleinke to talk about his new book entitled Bleeding Edge: The Business of Health Care in the New Century. A medical economist and author living in Denver, Kleinke advocates a true partnership between hospitals and physicians--a marriage with both parties contributing equally to the relationship. He believes that "physicians and people who are running the administrative infrastructures of hospitals and other facilities need to recognize that they are equal partners in a death struggle against the insurers for ultimate control of the premium and the consumer." Though physicians are sure to balk at the suggestion that they become "captive" to the hospital, Kleinke explains that, "captivity is a necessary condition before they can work functionally together and take on managed care and contract directly with consumers, employers, and the government." Kleinke discusses five trends that he explores in his book: risk assumption, consumerism, consolidation, integration, and industralization.     

A Service Provider's Elicitation of Its Customers’ Demand Distributions by a Price Mechanism

In a service environment a service provider needs to determine the amount and kinds of capacity to meet customers’ needs over many periods. To make good decisions, she needs to know the probability distribution of her customers’ demand in each period. We study a situation in which customers’ demand for a given service is random in each period, but inelastic, or modeled well by this assumption, and cannot be delayed to the next period. This article presents a mechanism that allows a service provider to learn the distribution of a customer's demand by offering him a set of contracts through which he can partially prepay for future service for a reduced cost for units of service based on anticipated needs. We describe the form of a set of contracts that will cause the customer to reveal his demand distribution as he minimizes his expected costs. To justify the effort of organizing and offering contracts, we present an application that demonstrates the cost savings to the service provider with better capacity planning using the truthfully elicited distribution.     

Interdisciplinary, functional approach to quality review

Dramatic changes in the standards of the Joint Commission on Accreditation of Healthcare Organizations, as part of its "Agenda for Change," pose new challenges for health care managers. The goal of the "Agenda for Change" is to focus accreditation on the actual performance of important functions while continuously stimulating improvement in the organization's performance and outcomes of care. In 1994, seven important functions--improvement of performance, leadership, management of information, assessment of patients, education of patients and families, operative and other procedures, and treatment of patients--were identified by JCAHO. Performance, as defined by JCAHO, can be measured through observing specific dimensions, such as, availability, safety, timeliness, effectiveness, continuity, efficiency, and respect and caring. These are considered important elements in the determination of quality, value, cost, and patient outcome. In 1995, JCAHO identified 11 important functions--patient rights and organizational ethics, assessment of patients, care of patients, education, continuum of care, improving organizational performance, leadership, management of the environment of care, management of human resources, management of information, and prevention and control of infection. In addition each institution has the opportunity to decide by prioritization where it wants to devote resources. This article reports on one hospital's response to the new JCAHO initiatives.     

Aus Fehlern Iernen

Learning from blunders. Experiences of an executive coach with problems and solutionsNot too often, even rarely, we are in a situation to talk about blunders or shortcomings within our coaching community. That really is a pity, because a discussion like this combined with reflection and feed back is the best and only way for a coach to avoid professional mistakes in his future. So this article is “somehow another kind” of contribution. The author reports his own 18 years of “blunder-experience” as well as professional mistakes of other coaches which he observed in mentor coachings and supervisions, he suggests outcomes, consequences and solutions. Topics are: Anger, aggression and “struggles of power” within the coaching process; dependence versus (internal) independence of a coach; transference and counter-transference within the coaching process; peanut politics within a coaching process. Result: the coach himself, his core values, his boldness directed to social risks and to natural consequences — combined with appreciative conversation and respecting clients — makes out the core dissolving capacity. Without mentor coaching and professional supervision every coach would be trapped into his personal “trap of mistakes” — and even worse: without recognizing this dilemma.     

Renegotiating health care. Interview by Richard L. Reece

Richard L. Reece, MD, interviewed Leonard Marcus, PhD, on May 21, 1999, to talk about his book, Renegotiating Healthcare, Resolving Conflict to Build Collaboration, and the Program for Healthcare Negotiation and Conflict Resolution he directs at the Harvard School of Public Health. Dr. Marcus discusses conflict management and negotiation in an industry besieged by change . He says, "we are, in effect, renegotiating the very assumptions and premises that have guided the health care system over the last few decades." In such a turbulent environment, it is crucial that all stakeholders can move to higher ground and resolve their differences instead of escalating the war. The key, Marcus says, is providing options through interest-based negotiation and mediation, so that the parties can look at the bigger picture and reconnect with what they are all committed to accomplishing in health care. While conflict can be destructive, it also can provide opportunities for people to look at where there are problems, to identify and correct those problems, and achieve something even better than what they began with through the process.     

Recognizing the power of diversity

"The trouble with the future is that it usually arrives before we are ready for it." While Arnold H. Glasgow did not have diversity in mind when he made this statement, his thought is relevant to that topic nevertheless. In fact, almost everything in the health care environment of the 1990s is fluid, making the future a question mark. Among these changes is the demographic composition of students entering medical school and of patients. Consider the following. While 14 percent of today's physicians are people of color, that number increases to 25 percent for current medical students. In the past 10 years, the number of female physicians has seen the largest percentage growth, followed by American Indians, Blacks, and Hispanics. Physician executives who have vision and energy can capitalize on this demographic revolution and convert diversity into a competitive advantage once its boundaries are understood.     

How to fight the regulator glut: the role of the HCFA-type survey

More and more hospitals in this country are being threatened by the removal of their Health Care Financing Authority (HCFA) Medicare Certification. A perception of competitiveness among HCFA, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and other organizations has heightened this concern. This unpleasant situation has provoked many hospitals to prevent any type of regulator decertification. One of the practical methods of prevention is the use of a HCFA-type survey. These surveys prepare institutions for unexpected, unarmored review by regulators and should be part of the quality improvement (QI) process even in institutions with limited resources. This article discusses the means to accomplish the HCFA-type survey. The development of the survey process involves institutional commitment, hospital policy and procedures, a department review schedule, selection of review personnel, preparation of review personnel, record keeping, and department education.