Health Services Management Research

Published by SAGE Publications
Online ISSN: 1758-1044
Publications
Article
The extent to which post-1965 declines in infant mortality could be attributed to (1) US medical and antipoverty programs and/or (2) internationally available medical advances was examined using data on infant, neonatal, and postneonatal mortality rates (IMRs, NMRs, PNMRs) in four western countries. The results showed that while post-1965 improvements occurred internationally, the US IMR improvements doubled that occurring elsewhere. Much of this advantage was attributable to post-1965 US PNMR improvements, which more than offset a slowing in the reduction of international PNMRs. In contrast, international effects contributed more to US declines in NMRs than did uniquely-United States factors.
 
Article
In-patient activity of Fife Ear, Nose and Throat (ENT) wards and of Fife ENT consultants are higher than the Scottish averages. Out-patient activity appears to operate at a lower level and hundreds of patients remain on the Fife waiting list for operations. An analysis of 731 patients on the ENT waiting list in 1989 showed that 15% had been waiting for over three years. Over 350 hours of theatre time and over 3,200 in-patient bed days would be required to clear this waiting list. Adopting a guillotine tonsillectomy operative procedure without anaesthesia would make a major contribution to a rapid reduction of the waiting list. Although this is reported to be quick, relatively painless and remarkably free from haemorrhagic complications, it appears not to be acceptable in our medical culture at the moment. A life table analysis suggests that Fife is failing to operate on patients at a rate compatible with the needs of the community: current trends of operating suggest that over one half of patients will be on the waiting list for operations three years after being placed on it. The Secretary of State's 1989-90 waiting list initiative, the appointment of an extra ENT consultant and the allocation of additional operating theatre time may help to resolve these difficulties.
 
Article
Much of the current literature on healthcare professionals developing management roles has focused almost exclusively upon hospital doctors. This paper seeks to redress this imbalance and explores the emergence of the professions allied to medicine (PAMs) as clinical managers. A comparative study of 25 English and Scottish radiographer managers were interviewed. From the interviews, a number of themes were developed associated with moving from a clinical professional to a clinical manager and were analysed using domain theory. These themes included management, professionalism, management style, conflicts between the role of both manager and professional, and role change. Radiographer managers are forming new 'hybrid' managerial roles, which have been developing within a changing NHS. A definite tension was seen in this role change, and the transition has not been easy for this group of PAMs. However, they have shown resilience in undertaking both operational and strategic management decisions, while using their clinical background in their decision-making and have much to offer the management process.
 
Article
As the environment surrounding the health care industry has changed, the ability of administrators to manage these relationships remains very limited due to their ever-increasing complexity. These organizational relationships offer both challenges and opportunities for innovative strategies that address the issues of coordination and control. As these environmental changes take place, the application of information systems technology becomes more important for managing these relationships and achieving competitive advantages. A theoretical model is presented to serve as a basis for empirical investigations into the role of information systems technology in health care organizations--more specifically teaching hospitals.
 
Article
This case study elaborates the aftermath of the Blom-Cooper Inquiry (1992), which forced the special hospital, Ashworth, into a radical 'culture change'. To this end, two groups of external consultants--a management consultancy and a professional task force--were introduced into the hospital. Newly established ward managers were to spearhead the organizational change by bringing social and clinical order to the wards over which the higher management had lost control. Few studies have mapped out the interaction between segments of an organization and expert outsiders. In this study, the interaction of the ward manager to the newly appointed external management consultancy and task force was analysed. It was clear that ward managers rated poorly the efforts of the management consultancy and task force--it was considered that they were not giving value for money. The task force rated slightly more favourably than the management consultancy. The fact that the management consultancy did not have ward credibility in this closed forensic setting was attributed to low prestige. The management consultancy also failed to fulfill the organizational ambitions of ward managers, who wished to be central to the hospital's major decision-making process.
 
Article
In order to improve the existing situation in the Greek health sector, there is a pronounced need for flexible planning methods, together with the development of long-term perspectives on policy formulation. The team started with the collection of relevant data, since the first priority was to have a detailed knowledge of the current situation and conditions upon which projections of likely future developments can be based. The aim of this paper is to identify a reliable method for the estimation of future admissions to hospitals, by age groups and sex. These estimates have been used as the basis for projecting hospital bed requirements by the final year of the planning period (2011). Accurate knowledge and analysis of hospital bed requirements in the future would be a fundamental aid to health care planning given that the increase in the proportion of elderly people will lead to differences in the demand for health services. To reduce uncertainty, a main parameter has been introduced and used in all projections, with very limited total variation. Although all relevant studies resulted in a rigid, one estimation (projection) point, we have estimated upper and lower limits of projections, to make the corresponding plan more flexible.
 
Article
The rapidly growing area of osteopathic medicine takes us beyond high technology, life-saving equipment, or at least the most accurate diagnostic test. Whether it is called 'alternative', 'complementary' or 'holistic' medicine, it cannot be ignored as a legitimate healthcare choice, with well-defined benefits for healthcare consumers. This paper examines the history, development, philosophy of practice and challenges facing the viability of osteopathic medicine. More specifically, we address the following key questions: What is osteopathy medicine? What role does osteopathic medicine play in the provision of health services? What challenges face this professional group? And is osteopathic medicine an alternative approach to healthcare?
 
Article
For measuring behaviour of National Health Service (NHS) staff, 360-degree assessment is a valuable tool. The important role of a clinical director as a medical leader is increasingly recognized, and attributes of a good clinical director can be defined. Set against these attributes, a 360-degree assessment tool has been designed. The job description for clinical directors has been used to develop a questionnaire sent to senior hospital staff. The views of staff within the hospital are similar irrespective of gender, post held or length of time in post. Analysis has shown that three independent factors can be distilled, namely operational management, interpersonal skills and creative/strategic thinking. A simple validated questionnaire has been developed and successfully introduced for the 360-degree assessment of clinical directors.
 
Article
Rees and Cooper (1990) used self-reports of sickness absence during the previous six months as a dependent measure in a diagnostic survey of stress in one health district. Comparison of self-reports with actual sickness absence showed that it achieved a high level of association (0.95) and can be recommended as an alternative to actual sickness data in studies in which, for whatever reason, actual sickness absence is difficult to obtain.
 
Article
The purpose of this research was to consider why absenteeism in Health and Social Care is so high and to suggest proactive changes in organization activity to address this. The research took a multimethod approach with a quantitative emphasis; there were three parts: (i) quantitative survey questionnaire; (ii) analysis of absenteeism and related secondary data; and (iii) qualitative data from other questions in survey and discussion groups. The quantitative emphasis in the research is appropriate, given the gap identified in the literature. Perceived limitations are that the study considers just one part of the overall system. The research indicates that managers underestimate staff absence levels and almost half believe absenteeism cannot reduce. Professional managers were more negative and over half of nurse managers believed that absence could not reduce. Unless there is a systematic systemic change in organizations, which changes managers' attitudes and understanding of absence with a consequent change in activity across the absence continuum, there is no prospect of a sustained reduction in absence levels. Manager impact and role in absence management are poorly covered in research, so this research helps inform those gaps.
 
Article
Substance abuse treatment programmes depend on boundary spanning to identify opportunities and threats, and represent their interests to stakeholders such as licensing entities and regulators. This study sought to identify director, client, unit and market factors associated with active director boundary spanning. Using data from the 1995, 1999-2000 and 2005 waves of a national survey of outpatient substance abuse treatment units, generalized estimating equation regression models tested associations between predictors and five aspects of directors' self-reported boundary spanning. Directors licensed as substance abuse treatment counsellors spent more time than average consulting with other treatment providers and making presentations in the community. Older directors spent less time consulting with other treatment providers, making community presentations and liaisoning with monitoring organizations. The few associations between client unemployment and director boundary spanning were positive; the two associations between the percentage of clients who were African-American and boundary spanning were negative. Private ownership and being based in larger organizations were negatively associated with some types of boundary spanning. Perceived competition for public support was positively associated with all measures of boundary spanning. Directors of treatment organizations may improve treatment practices and political leverage by directly, but selectively, interacting with key external stakeholders.
 
Article
This study analyzes cooperative interorganizational relationships (IORs) between two different types of health care organizations. It proposes a power perspective analysis to better understand why IORs which represented many rational advantages to both partners were so difficult to realize in practice and often with only modest results. Hypotheses are tested explaining how physicians, as groups, exert important controls and can largely determine the results that can be realized in any IOR aimed at modifying medical education and patient referrals.
 
Authorship of clinical notes 
Article
There are opportunities to improve quality and safety of care provided to adult patients. The Plummer Project of the Department of Medicine at the Mayo Clinic (Rochester, MN, USA) is an initiative to redesign outpatient practice. We used multidisciplinary teams to standardize the tasks essential to improve patient care. With the initiative to standardize the rooming process, patient care and safety improved with greater accuracy of the medication list. The standardization also improved physician efficiency because trained clinical assistants helped address the needs of the patient. Physicians were satisfied by the new process and the technology enhancements. Clinical assistants were also highly satisfied by the training process. The quality and safety of patient care can be significantly improved by practice redesign. This practice redesign was satisfying for all, especially the patients, physicians and support team in our practice.
 
Article
The primary health-care centre (PHCC) participating in the study has had financial problems for several years and it has been particularly difficult to recruit general practitioners (GPs). As a result, the access rate to the PHCC was low. The purpose of this study was to increase the access rate to the PHCC and to make the most efficient use of the staff by introducing a structured patient sorting system. All personnel were involved in the implementation process and participated regularly in interdisciplinary work-groups. A variety of Drop-in receptions were created and a manual for sorting patients by condition was introduced. The main finding was that the total access rate to the PHCC increased by 27% and that each staff member increased their personal access rate by an average of 13%. Eighty-three percent of the patients who were initially treated by the rehabilitation team were treated solely by the team and did not need to see a GP. No medical backlashes were reported. These findings indicate a more efficient use of the personnel. Furthermore, both personnel and patients indicated an improvement in the possibility to book patient appointments after the introduction of the structured patient sorting system.
 
Article
This paper investigates differences between various HMO types (eg, staff model, group model, IPA model) in their access and quality of care outcomes. Several sources of evidence are analyzed, including research findings reported in the health administration literature, survey data from a random sample of 42 HMOs, and accreditation data gathered from 26 HMOs in four states. Consistent with previous research, both the random sample survey data and the accreditation data indicate that group and staff model HMOs score more favorably than IPA models in terms of the level of services provided, preventive care, and various quality of care outcomes. Data from the random sample survey indicate that IPA models score more favorably on measures of patient satisfaction and access outcomes. These findings are consistent with speculation that IPAs trade off utilization and quality controls for patient access and physician autonomy. Contrary to speculation, the effect of HMO type on access and quality may be independent of the degree to which physicians are financially and organizationally tied to the HMO.
 
Article
With increasing competition in the local and regional healthcare markets, and growing interest in assessing the effectiveness of services and patient outcomes, satisfaction measures are becoming prominent in evaluating the performance of the healthcare system. This study examines the independent effect of predisposing, enabling and medical need factors on perceived access to care with particular focus on insurance plans. A survey questionnaire is developed to investigate access limitations at three levels: (1) the health plan, (2) the individual provider(s) and (3) the healthcare organization. In addition, shortage of providers, residents' perceptions of their health status, satisfaction with access to care and socio-demographic indicators are incorporated into the analysis. Multivariate logistic regression is used to assess the independent effects of the above factors on a dichotomous dependent variable--residents' overall satisfaction with access to healthcare services. The most salient determinants of overall satisfaction with access to care were the type of health insurance plan, cost of insurance premiums, co-payments, difficulty with obtaining referrals, self-rated general health, the opportunity cost of taking time to see a provider (measured by the loss of hourly wages), marital status and the age factor over 80 years.
 
Article
Open-access or advanced-access scheduling, which opens the clinic calendar to patients without requiring them to schedule far in advance of the visit, is being introduced in primary care for the purpose of improving access. None of the evaluations reported to date have measured differences in actual visits that might be associated with different scheduling systems. The purpose of this study was to compare utilization of visits to primary care providers for patients served by an open-access clinic with utilization patterns of patients served at clinics not using open-access scheduling. We hypothesized that the odds that a continuing patient received more than one primary care visit would be greater in the clinic where open-access scheduling was in use than in comparison clinics. Our study provides mixed support for the hypotheses. After adjustment for case mix, stable chronic patients treated in open-access clinics may sometimes have greater odds of receiving two or more preventive care visits. However, these effects do not occur in all clinics, suggesting that other clinic characteristics may overcome the effects of open-access scheduling.
 
Article
The provision of physiotherapy via general practitioner (GP) 'direct access' arrangements or in primary care itself has become increasingly common in the UK. Evidence on the economics and the cost-effectiveness of alternative methods of organizing access to physiotherapy services is reviewed, and the likely impacts of different organizational models are discussed. GP direct access physiotherapy and primary care provision appear to have a lower average cost than consultant access physiotherapy models, while GP direct access appears to minimize health care resource use per patient. Primary care physiotherapy provision appears to minimize the costs to patients of seeking care, and appears to generate a greater demand for service than other models. The extent to which physiotherapy provision in primary care can substitute for physiotherapy and other resources in the hospital sector is discussed, as is the extent to which patients may benefit from receiving physiotherapy in primary care. It is argued that continued expansion of access to physiotherapy should be critically appraised, and its ability to improve health status compared with that achievable in alternative patient groups who might benefit from physiotherapy in hospital or rehabilitation settings.
 
Article
Given a choice, hospitals would prefer to admit a patient with the potential to contribute to an accounting profit and prefer not to admit a patient with the potential to contribute to an accounting loss. It is suggested that if all hospitals found the same DRGs to be unprofitable, access to inpatient care would be denied those patient types. A set of 509 hospitals was stratified according to bedsize, Medicare load, type of control, teaching status and geographic location. The 10 most and 10 least profitable DRGs were identified for each hospital category and a Spearman's rank order correlation was used to determine the similarity or dissimilarity across hospital category. The results indicate that the more alike hospitals are in terms of bedsize, Medicare load and teaching status, the more alike are the DRGs that are determined to be unprofitable (or profitable). Conversely, the less alike they were on these characteristics, the less alike were the unprofitable (or profitable) DRGs. There were no differences evident when the hospitals were classified according to type of control or geographic location. These results are generally encouraging in terms of potential access but disturbing in terms of possible further financial threat to rural hospitals.
 
Article
This paper examines the extent to which hospitals that are under external contract management engage in service duplication, as well as the degree to which the various services they offer contribute to or detract from community access. The study incorporates all USA hospitals using data from the American Hospital Association Annual Survey Database, supplemented by county level measures obtained from the area resource file (ARF). Using data on the 3794 hospitals classified as acute care facilities in 2002, we performed a set of logistic regressions that analyzed whether a hospital offered each of 74 distinct services. For each service (regression), key independent variables measured the number of other hospitals in the local market area that also offered the service. Local area market definitions are the areas circumscribed by the hospital within distances of 10 and 20 miles. Results suggest that contract-managed (CM) hospitals display a more competitive pattern (service duplication) than hospitals in general, but CM hospitals that are the sole provider of services locally are less likely to offer services than traditionally managed sole hospital providers. Contract management does not appear to offer any particular advantages in improving access to hospital services.
 
Article
The objective of this paper is to investigate the relevance of access to hospital services in explaining utilization rates at a District Health Authority level in the UK. In order to test the hypothesis that access is important, it is necessary to develop a means of scoring access factors and then combining these scores with other more recognized influences on hospitalization rates e.g. deprivation measures. Acknowledging that hospitalization rates are not merely products of a population's socio-economic characteristics, the effect of accessibility to hospital services for the resident population is investigated through the derivation of an access score using both private and public transport from electoral ward of residence. Deprivation and accessibility to services were both found to be significant factors in determining hospitalization rates at electoral ward level. The chosen supply variable — number of GPs — was not found to be significant in any of the models developed using linear regression techniques. To conclude, it appears that access plays an important role in determining hospitalization rates within a given population. If high hospitalization rates are accepted as an indicator of effectively met demand then policy makers may have to consider increasing the accessibility of hospital services.
 
Article
This report investigates the use of linear and travelled route (transit network-based) distances in estimating the accessibility of hospitals to patients, for some selected hospital admission diagnostics. For patients admitted to 14 public hospitals in Rio de Janeiro City, during 1996, under the ICD-9 headings "Complications of Pregnancy, Childbirth and the Puerperium" and "Disorders of the Circulatory System", average distances between the patient's district of residence and hospital of admission were calculated (both as Euclidean and as network-based distances). Data were obtained from the country's public health data processing agency. Geographic co-ordinates were obtained for districts of residence from the postal codes of the patients' residences. Distances were estimated with the TransCAD Geographical Information System, based on a map of the city transit network. There were 8654 patients admitted under the "Complications of Pregnancy" heading and 3439 under "Disorders of Circulatory System". Variations of up to a factor of 5.3, and up to 34 km, could be identified between linear and network estimates. While recognizing that network estimates have advantages, the literature on accessibility frequently argues that aerial estimates are a good approximation for those. The present results show that this is not necessarily the case.
 
Article
This paper describes a study carried out in the North Western Health Region of England where it is policy to provide access to regionally supplied specialist services on an equal basis to all component Health Districts. The results, however, suggest substantial differences in uptake depending on the proximity of the District of residence of the patient to the location of such specialist service. Throwing light on this phenomenon proved difficult because many important Regional services are hard to disentangle from the 'normal' District services with which they are organisationally linked. Also diagnostic classification schemes do not always provide a clear indication of those patients who require the super-specialist service.
 
Article
Background: This paper presents the findings of three multisite evaluations of Experience-Based Co-design (EBCD) programmes conducted in Emergency Departments (EDs) and associated departments in seven public hospitals in New South Wales, Australia. Method: Data for the evaluations were derived from: EBCD documentation provided by the participating sites; interviews with 117 key informants; performance data and the policy and academic literature on EBCD. Results: Respondents described EBCD as a successful and sustainable method of improving the individual patient experience and the overall quality of a health service. Demonstrated successes were reported to lead to aspects of the EBCD approach spreading within services. However, like any quality improvement activity, EBCD was not without its challenges. The principal challenge particular to the EBCD projects outlined here was their deployment in ED settings. Because of their ambulant patient populations, these settings made sustaining consumer engagement for the duration of the project problematic and required tailoring EBCD to accommodate consumers' involvement preferences and constraints. Conclusion: The primary strength of EBCD over and above other service development methodologies was reported to be its ability to bring about improvements simultaneously in both the operational efficiency and the inter-personal dynamics of care. However, careful consideration must be given to the constraints inherent in transient patient specialties and what needs to be done to tailor EBCD to suit the particular setting in which it is deployed.
 
Article
Triage is the term used to describe the formal process of assigning urgency categories to patients arriving in a hospital accident and emergency department. This paper uses insights from literature on management control, medical sociology and nursing to illuminate the results of a research study comparing formal triage with an informal prioritisation process carried out by nurses. Topics discussed include whether triage is a bureaucratic process, whether it allows nurses' intuition to be expressed, whether it masks the urgency of the condition of the small number of seriously injured or ill patients, and whether responsibility for decisions on urgency should be separated from responsibility to act on those decisions. It is concluded that managers must consider these questions in the light of arrangements in their own hospital; departmental layout as well as the nursing staff's experience and commitment need to be taken into account.
 
Article
This study aimed to examine the scope of activities performed by hospital volunteers. A survey was conducted on 3055 hospitals, randomly selected throughout Japan. Attention was also paid to the accident-prevention systems instituted by those facilities. Almost one-third (36.5%) of all hospitals had some hospital volunteers. About 60% (59.9%) of hospitals conducted volunteer activities more than once a week. Recreation (50.1%) was the most common role of the volunteers. The other activities in decreasing order were: conversation partners (45.8%), music and entertainment (43.7%), wheelchair pushing (41.8%) and helping administration (36.3%). Both direct and indirect contact between volunteers and patients was prevalent. Less than half of the hospitals had accident-prevention systems, such as guidelines for volunteer activities (except for Volunteer Insurance). Hospitals that had a volunteer coordinator tended to have significantly more accident-prevention systems. It is, therefore, important to establish volunteer coordinators in order to prevent accidents during hospital volunteer activities.
 
Article
Our goal was to assess how different hospital wards react to influenza epidemics, and whether related specialties cooperate in coping with winter bed crises. Study design: The Lazio Hospital Information System (HIS) dataset from July 1998 to June 2001 was used for the study. The HIS collects data on all hospital discharges. We considered diagnosis-related groups (DRG) as the reason for hospital stay and used DRG to classify admissions as influenza related or influenza unrelated. Time series analysis of daily bed occupancy in different specialty areas by influenza-related and influenza-unrelated cases was performed. Generalized additive models (GAMs) were used to take the effect of short-term and seasonal bed occupancy into account on influenza-related occupancy. Influenza-related bed occupancy ranges from 770 patients/day during the influenza season to 525 patients/day during the rest of the year. Daily occupancy by influenza-related cases represents 2.8% of total hospital occupancy and 7% of general medicine occupancy during the influenza season. When comparing the influenza season with the rest of the year, general medicine occupancy by influenza-related cases increases by 51% versus the 25-32% increase in other specialty wards. Little change in daily occupancy by influenza-unrelated cases was observed in all specialties when comparing the influenza season with the rest of the year. Hospital specialty wards react poorly and single handedly to a minor and predictable burden. Any winter bed crisis in the Lazio region is probably the result of defective management of available beds more than excess in demand.
 
Article
New public management accountability is increasingly being introduced into health-care systems throughout the world - albeit with mixed success. This paper examines the successful introduction of new management accounting systems among general practitioners (GPs) as an aspect of reform in the Italian health-care system. In particular, the study examines the critical role played by the novel concept of an 'ethical budget' in engaging the willing cooperation of the medical profession in implementing change. Utilizing a qualitative research design, with in-depth interviews with GPs, hospital doctors and managers, along with archival analysis, the present study finds that management accounting can be successfully implemented among medical professionals provided there is alignment between the management imperative and the ethical framework in which doctors practise their profession. The concept of an 'ethical budget' has been shown to be an innovative and effective tool in achieving this alignment.
 
Article
This paper reports on the findings of a representative survey of senior managers within New Zealand's health system. Respondents report most favourably upon the implementation of a new organisational structure, service management, which appears to have largely replaced the traditional division of health services into hospitals and community services. Service management, which is the decentralisation of decision making to integrated patient groupings, i.e. medicine, surgery, mental health, women's health, primary health care etc., appears to have been remarkably successful, in the view of the respondents, in achieving greater efficiencies, better quality care, better decision making about priorities and greater accountability of doctors. A majority of respondents consider that services have replaced hospitals as organisational entities. Significant progress is reported in the integration of hospital and community services, primary and secondary care, preventive and treatment services and of public, private and voluntary services through service management. The findings point to a new paradigm which may be of fundamental significance in the future organisation of health services.
 
Article
This paper discusses the issues involved with determining an appropriate discount rate for not-for-profit hospitals and develops a method for computing measures of systematic risk based on a hospital's own accounting data. Data on four hospital management companies are used to demonstrate the method. Results indicate the need for sensitivity analysis in the selection of estimation methods and in the final determination of a discount rate.
 
Article
The adoption of new medical technologies has received significant attention in the hospital industry, in part, because of its observed relation to hospital cost increases. However, few comprehensive studies exist regarding the adoption of non-medical technologies in the hospital setting. This paper develops and tests a model of the adoption of a managerial innovation, new to the hospital industry, that of cost accounting systems based upon standard costs. The conceptual model hypothesizes that four organizational context factors (size, complexity, ownership and slack resources) and two environmental factors (payor mix and interorganizational dependency) influence hospital adoption of cost accounting systems. Based on responses to a mail survey of hospitals in the Chicago area and AHA annual survey information for 1986, a sample of 92 hospitals was analyzed. Greater hospital size, complexity, slack resources, and interorganizational dependency all were associated with adoption. Payor mix had no significant influence and the hospital ownership variables had a mixed influence. The logistic regression model was significant overall and explained over 15% of the variance in the adoption decision.
 
Histogram: Dependent Variables: Total Variable Costs
(continued) 
Regression Analysis-Normal Distributional P-P Graph-for Standardized Residual Error 
Article
According to the 2004 US Renal Data System's annual report, the incidence rate of chronic renal failure in Taiwan increased from 120 to 352 per million populations between 1990 and 2003. This incidence rate is the highest in the world. The prevalence rate, which ranks number two in the world (Japan ranks number one), also increased from 384 to 1630 per million populations. Based on 2005 Taiwan national statistics, there were 52,958 end-stage renal disease (ESRD) patients receiving routine dialysis treatment. This number, which comprised less than 0.2% of the total population and consumed $2.6 billion New Taiwan dollars, was more than 6.12% of the total annual spending of national health insurance during 2005. Dialysis expenditures for patients with ESRD rank the highest among all major injuries (traumas) and diseases. This article identifies and discusses the risk factors associated with consumption of medical resources during dialysis. Instead of using reimbursement data to estimate cost, as seen in previous studies, this study uses cost data within organizations and focuses on evaluating and predicting the resource consumption pattern for dialysis patients with different risk factors. Multiple regression analysis was used to identify 23 risk factors for routine dialysis patients. Of these risk factors, six were associated with the increase of dialysis cost: age (i.e. 75 years old and older), liver function disorder, hypertension, bile-duct disorder, cancer and high blood lipids. Patients with liver function disorder incurred much higher costs for injection medication and supplies. Hypertensive patients incurred higher costs for injection medication, supplies and oral medication. Patients with bile-duct disorder incurred a significant difference in check-up costs (i.e. costs were higher for those aged 75 years and older than those who were younger than 30 years of age). Cancer patients also incurred significant differences in cost of medical supplies. Patients with high blood lipids incurred significant differences in cost of oral medication. This study identified the relationship between cost and risk factors of dialysis procedures for ESRD patients based on average variable costs for each dialysis treatment. The results show that certain risk factors (e.g. aged 75 and older, hypertension, bile-duct disease, cancer and high blood lipids) are associated with higher cost. The results from this study could enable health policy makers and the National Health Insurance Bureau to design a fairer and more convincible reimbursement system for dialysis procedures. This study also provides a better understanding of what risk factors play more influential roles in affecting ESRD patients to receive haemodialysis treatment. It will help policy makers and health-care providers in better control or even prevent the disease and manage the distribution of the treatment. In addition, with the results from the analysis of cost information, we can tell which risk factors have more impacts on the dialysis cost. It will further help us control the cost for those high-risk dialysis patients more efficiently.
 
Article
The aim of this study was to understand the environment of health care, and how clinicians and managers respond in terms of performance accountability. A qualitative method was used in a tertiary metropolitan teaching intensive care unit (ICU) in Sydney, Australia, including interviews with 15 clinical managers and focus groups with 29 nurses of differing experience. The study found that a managerial focus on abstract goals, such as budgets detracted from managing the core business of clinical work. Fractures were evident within clinical units, between clinical units and between clinical and managerial domains. These fractures reinforced the status quo where seemingly unconnected patient care activities were undertaken by loosely connected individual clinicians with personalized concepts of accountability. Managers must conceptualize health services as an interconnected entity within which self-directed teams negotiate and agree objectives, collect and review performance data and define collective practice. Organically developing regimens of care within and across specialist clinical units, such as in ICUs, directly impact upon health service performance and accountability.
 
Article
The scope of this research has been to investigate the satisfaction of Greek patients hospitalized in a tertiary care university public hospital in Alexandroupolis, Greece, in order to improve medical, nursing and organizational/administrative services. It is a cross-sectional study involving 200 patients hospitalized for at least 24 h. We administered a satisfaction questionnaire previously approved by the Greek Health Ministry. Four aspects of satisfaction were employed (medical, hotel facilities/organizational, nursing, global). Using principal component analysis, summated scales were formed and tested for internal consistency with the aid of Cronbach's alpha coefficient. The non-parametric Spearman rank correlation coefficient was also used. The results reveal a relatively high degree of global satisfaction (75.125%), yet satisfaction is higher for the medical (89.721%) and nursing (86.432%) services. Moreover, satisfaction derived from the hotel facilities and the general organization was found to be more limited (76.536%). Statistically significant differences in participant satisfaction were observed (depending on age, gender, citizenship, education, number of previous admissions and self-assessment of health status at the first and last day of patients' stay) for the medical, nursing and hotel facilities/organizational dimension, but not for global satisfaction. The present study confirms the results of previously published Greek surveys.
 
Article
A basic managerial problem in decision making is to synthesise and priorise information relating to the achievement of organisational goals and objectives. This paper discusses the role of critical success factors in health services planning as a means for sorting out and specifying relevant information necessary for achieving organisational goals and managerial objectives. The proposed approach enhances existing planning procedures for health care organisations. Within a conceptual framework of the health care system, managerial insights are provided for the realisation of organisational goals via measurable managerial objectives using critical success factors as pointers to success. More importantly, this paper introduces a planning model which incorporates the CSF concept for developing new health care programmes and for evaluating or restructuring existing programmes.
 
Article
Hospital-acquired infections (HAIs) significantly increase both the patient's length of stay and the cost of disease. For this reason, HAIs are one of the most important problems that intensive study is devoted to in many countries around the world. The purpose of this study is to investigate how having a HAI prolongs the length of stay and adds unnecessary cost to the patient. The study compared two matched groups and suggested that a patient with a HAI spent an additional 23 days in the hospital compared with a patient not affected with a HAI. The results also showed that a patient with a HAI had to pay more in almost all cost categories compared with a non-infected patient. The additional cost for an infected patient was calculated as 2026.70 US dollars. As a result of HAIs, the hospital had additional, but avoidable, expenses of 30,754 US dollars for 57 patients over a period of four months.
 
Article
The growing acceptance of evidence-based decision-support systems in healthcare organizations has resulted in recognition of information accuracy as a key area of organizational management. In the United States, rigid data mandates related to information management have met with some resistance from healthcare provider groups, who have traditionally found little relevance between personalized healthcare practice and accurate information. Variation in management practice poses quality problems in such an environment, since it precludes comparisons across larger markets or areas, a critical component of evidence-based quality assessments. In this study, a national census of health information managers was employed to provide a benchmark of the degree of such variation, examining how proper billing compliance practices vary across organization types as well as market area indicators. Findings here suggest that managers continue to ignore, to some extent, regulatory compliance standards, despite nationwide laws that mandate adoption of uniform compliance practices and programmes. The level of adoption of compliance management in this study varied significantly across practice characteristics and areas, suggesting the existence of barriers to cross-market comparative performance assessment.
 
Article
Objectives: A Primary Care Trust (PCT) used its position as lead commissioner in a health economy to search for efficiency gains and to improve the patient journey through accident and emergency (A&E) services in a hard-pressed acute hospital. The project generated an action research approach. As a by-product, we developed a model of the hospital system based on a case study that can be replicated and used to set utilization targets at the micro-level of the hospital organization. This addresses a gap in the literature on hospital utilization that currently focuses on macro-population levels of analysis or simulation models that demand complex data. Primary and secondary care services, in contrast, require a pragmatic model of utilization supported by a few key, readily available data items. Methods: Mixed quantitative and qualitative methods were adopted in an approach of collaborative enquiry among stakeholders of the health economy. We used the flexible planning tenet of action research that evolved into the subjective meaning tenet by which, to achieve authoritative findings, it was necessary to broaden the line of enquiry to address participants' perceptions. Results: We have described the current patient flow and a redesigned pathway through A&E services together with targets and action required to reduce admissions, delayed discharges and diagnostic waits in the emergency hospital system. Primary care had a key role in changing the culture, communication and treatment within A&E services. Conclusion: (i) This study was rapid and sustained a high level of energy and purpose among stakeholders. Action research is an appropriate method to apply to transformational change in the modernization of health-care systems; (ii) Modelling of system dynamics is a critical dimension to the success of whole system change; (iii) Primary care commissioning power is an under-used, but influential, lever for change. At a point when the PCT commissioning structure is under threat, this project exemplifies primary care's ability to engineer change in acute hospital services.
 
Article
We examined the findings of a recent national survey of healthcare executives that showed 90% of women but only 53% of men favoured efforts to increase the proportion of women in senior healthcare management positions. Using the theories of relative deprivation and social identity, we tested hypotheses to suggest the background, work characteristics and attitudes about existing discriminatory practices in their own organizations that correlate with respondents' views about affirmative action for women. Some support is evidenced for the two theories and explanations are suggested to account for apparent anomalies.
 
Article
This paper reports on a training programme using action learning sets designed to enhance the management abilities of health-care managers. Numerous independent reports in Australia, and around the world, have related the lack of management systems and processes to substandard health-care delivery. This has suggested a need for better approaches to the education, training and ongoing development of health-care managers, and this paper reports on an action learning approach trialled over a three-year period. Participant managers reported significantly greater levels of empowerment and self-efficacy after participation in the year-long action learning sets intervention. While too early to measure the translation of these reported individual improvements into specific management practice, the literature strongly supports more effective management practice among managers who report high levels of empowerment and self-efficacy.
 
Article
This article reports the results of a study designed to examine the relationship of environmental, organizational and structural factors, perceptions of key decision makers about competitive conditions, and changes in operational performance with the level of the marketing activities engaged in by 145 California hospitals. Measures assessing the impact of environmental conditions and the perception of the key decision makers were found to be related to the marketing activities of the organization. However, the relationship between measures which examined the structural and performance impacts on the marketing activities did not demonstrate the same predictive ability. The results suggest that marketing activities were affected by the key decision maker's assessment of the competitive nature of the environment, influence of key stakeholders, and tangible changes in the organization's task environment. Performance and other measures were not found to be as influential in determining these activities.
 
Article
As Hales (1986) has observed, the problem of much of the managerial research to date has been the reluctance to ask why managers behave in the way they do. The behaviour of general managers in tackling organisational change in the NHS needs to be viewed not only with respect to what is done but also with respect to how personal and organisational objectives are construed. In other words, the implementation of organisational change ultimately rests on how general managers perceive the nature of this change and their role in structuring their own personal and organisational objectives into appropriate activities. Examining the compatibility of managerial activities and the underlying values and intentions which support them is of critical importance in any cognitively-based approach. These intentions provide an important link between perceptions (i.e. how the organisation is construed) and behaviour (i.e. what activities managers choose to perform). Understanding the conceptual frameworks which underpin managerial activities could have profound implications for assessing the performance of general managers.
 
A model of local health-care providers, showing intermediate care in relation to organizational boundaries and health and social care activity. (An Acute Trust is a hospital. A Primary Care Trust provides community nursing and other services and for the purpose of illustration, is taken to include the family doctor service (general practice). Some primary care trusts will join with social service departments to provide social care.)
Impact on providers' budgets and on the health economy from a switch to intermediate care for Brent patients discharged from local hospitals
Article
Intermediate care is part of a package of initiatives introduced by the UK Government mainly to relieve pressure on acute hospital beds and reduce delayed discharge (bed blocking). Intermediate care involves caring for patients in a range of settings, such as in the home or community or in nursing and residential homes. This paper considers the scope of intermediate care and its role in relation to acute hospital services. In particular, it develops a framework that can be used to inform decisions about the most cost-effective care pathways for given clinical situations, and also for wider planning purposes. It does this by providing a model for evaluating the costs of intermediate care services provided by different agencies and techniques for calibrating the model locally. It finds that consistent application of the techniques over a period of time, coupled with sound planning and accounting, should result in savings to the health economy.
 
Article
The 1997 White Paper--The New NHS--on the future of the National Health Service accorded a high profile to the use of benchmarking as a means of improving efficiency over the following decade. Here, I examine the prospects for the successful adoption of benchmarking in the acute-hospital sector. A benchmarking model is superimposed upon a model of receptive contexts for change, and the components are used to explore the background to the development of benchmarking and likely attitudes towards its implementation. Where appropriate, empirical evidence is introduced to shed light on the ideas explored. I conclude that the wider political agenda accompanying benchmarking has potentially far-reaching implications for the re-distribution of resources on regional, or even national, bases. However, the steady drip-drip on stone is necessary to achieve results at local operational levels. Only by harnessing the strengths of extant cultures will efforts to identify and adopt the most efficient/effective medical practices succeed and potentially conflicting social tensions be resolved.
 
Article
Health-care organizations, particularly hospitals, are among the most complex organizations to manage. However, the executive selection processes these organizations have in place are poorly understood. The purpose of this study is to explore the executive selection processes employed by USA acute care hospitals and discern if such processes are related to environmental, structural and strategic organizational characteristics. We conceptualize this model using a configurational approach. We present an empirically derived taxonomy of hospitals based on executive selection processes, structural and environmental characteristics, and organizational strategy based on the Porter framework. Based on the analyses, three types of hospitals are identified: (1) small, rural, cost leaders with limited selection processes; (2) large, urban, differentiators, with a plan; and (3) small, rural, caught in the middle muddlers.
 
Article
There is increasing interest in the identification of predictors of risk for in-hospital mortality due to acute myocardial infarction (AMI). This study identified significant predictors of in-hospital mortality among AMI patients using a patient level clinical database. The study population consisted of 4167 cases admitted between October 1999 and April 2001 with a principal diagnosis of AMI to 36 hospitals in three US states. Of the 182 available variables in the clinical data set, 30 variables were used as candidate predictors, and 19 showed significant univariate association with AMI in-hospital mortality. By applying multiple logistic regression and stepwise selection, a final prediction model for AMI in-hospital mortality was developed. Variables included in the final model were age, arrived from cardiac rehabilitation centre, cardiopulmonary resuscitation (CPR) on arrival, Killip class, AMI with co-morbid conditions, AMI with complications, percutaneous transluminal coronary angioplasty (PTCA) performed, β-blockers given, angiotensin-converting enzyme (ACE) inhibitors given, Plavix given. A 10-variable in-hospital mortality prediction model for AMI patients, which includes both risk factors and beneficial treatment procedures, was developed. x ² goodness of fit test suggested a good fit for the model.
 
Article
An exploratory analysis of utilisation patterns of acute care hospitals in the Province of Alberta, Canada was carried out to develop a methodology for assessing bed utilisation profiles of acute care hospitals by levels of care. The utilisation of Alberta acute care hospital beds was measured in terms of primary, secondary and tertiary levels of hospital services. Patient origin-destination methodology was applied and a regionalisation perspective employed. The data used for this study were hospital separation abstracts compiled by all Alberta acute care hospitals during year 1986, this coincided with the most recent available Canadian census data. It was estimated that approximately 10-11% of Alberta beds were used for tertiary care as derived from population based utilisation rates and patient flow patterns. With respect to per capita measurement, the number of beds used per 1,000 residents was: 3.5 to 3.9 for primary, 1.2 to 1.6 for secondary, and about 0.6 for tertiary levels of care. Regression analysis revealed that the marginal cost per bed at each level was approximately 75-79, 87-88, and 201-209 thousand Canadian dollars per year in 1986 for primary, secondary and tertiary care respectively. The profiles thus estimated explained about 65% of per bed hospital cost variation.
 
Article
The aim of the study is to assess the validity of three measures of illness severity (prior year's hospital expenditures, Charlson and Elixhauser indices), by analysing the effect of introducing report cards on hospitals treating patients with acute myocardial infarction (AMI). Medicare claims data were obtained for 1992–1997 for AMI patients aged 65+. We used differences-in-differences regression analysis to assess the impact of report cards introduced in New Jersey and Pennsylvania on the illness severity of AMI patients with and without coronary artery bypass graft (CABG) surgery (relative to states without report cards). The analysis was conducted at the hospital level. For validation we used raw mortality and re-admission trends for AMI patients. While prior hospital expenditures suggest a considerable change in the illness severity of AMI patients in Pennsylvania relative to other states, raw mortality and re-admission trends in Pennsylvania are relatively consistent with the trend in the rest of the USA. In line with raw mortality and re-admission data, the Charlson and Elixhauser indices do not imply a considerable change in the severity of AMI patients in Pennsylvania. For CABG patients, illness severity – as measured by all three severity measurement methods – decreased after introduction of report cards, particularly in Pennsylvania. In conclusion, for AMI patients the Charlson and Elixhauser indices are a more valid measure of illness severity than prior year's hospital expenditures. After report cards were introduced, healthier AMI patients were more likely to receive CABG surgery, while sicker patients were avoided.
 
Adoption and diffusion of extended roles in the UK (cumulative) Source: Price (2006) 
Participation in extended role activities 
Minimum and maximum lengths of training reported for extended role activities 
Proportion of trusts that had recruited applicants with unaccredited and accredited training 
Managers' confidence in previous accredited and unaccredited training received by recruits 
Article
This paper examines the quality and consistency of postregistration training and development for extended role activities undertaken by radiographers. Although the undergraduate curriculum has changed to some extent to accommodate expanded role requirements, much of the training does not, and cannot, take place until radiographers are qualified and are in post. While undergraduate programmes in radiography must be approved by the Health Professions Council, and are normally accredited by the radiographers' professional body, the Society and College of Radiographers, much of the training provided for extended role activities is ad hoc and neither validated nor accredited. This paper reports the outcomes of a survey of imaging service managers and follow-up interviews with imaging service managers. Managers' views of the quality of training and development provided for extended role activities and their approaches to recruiting radiographers with extended role experience, were explored. The research identified concerns among managers regarding the training currently available and indicated potential career disadvantages for radiographers receiving unaccredited development. There is also some evidence of wastage arising from the duplication of training by trusts because of uncertainty about the standards of competence instilled by programmes.
 
Top-cited authors
Ali Mohammad Mosadeghrad
  • Tehran University of Medical Sciences
Ewan Ferlie
  • King's College London
Duska Rosenberg
  • University of London
Peter Spurgeon
  • The University of Warwick
Iestyn Williams
  • University of Birmingham