Search

Purpose: This study sought to describe features of the physical space in which practices integrating primary care and behavioral health care work and to identify the arrangements that enable integration of care., Methods: We conducted an observational study of 19 diverse practices located across the United States. Practice-level data included field notes from 2-4-day site visits, transcripts from semistructured interviews with clinicians and clinical staff, online implementation diary posts, and facility photographs. A multidisciplinary team used a 4-stage, systematic approach to analyze data and identify how physical layout enabled the work of integrated care teams., Results: Two dominant spatial layouts emerged across practices: type-1 layouts were characterized by having primary care clinicians (PCCs) and behavioral health clinicians (BHCs) located in separate work areas, and type-2 layouts had BHCs and PCCs sharing work space. We describe these layouts and the influence they have on situational awareness, interprofessional "bumpability," and opportunities for on-the-fly communication. We observed BHCs and PCCs engaging in more face-to-face methods for coordinating integrated care for patients in type 2 layouts (41.5% of observed encounters vs 11.7%; P < .05). We show that practices needed to strike a balance between professional proximity and private work areas to accomplish job tasks. Private workspace was needed for focused work, to see patients, and for consults between clinicians and clinical staff. We describe the ways practices modified and built new space and provide 2 recommended layouts for practices integrating care based on study findings., Conclusion: Physical layout and positioning of professionals' workspace is an important consideration in practices implementing integrated care. Clinicians, researchers, and health-care administrators are encouraged to consider the role of professional proximity and private working space when creating new facilities or redesigning existing space to foster delivery of integrated behavioral health and primary care., (© Copyright 2015 by the American Board of Family Medicine.)

To achieve quality improvement in hospitals requires greater attention to systems thinking than is typical at this time, including a shared understanding across different levels of the hospital of the current state of quality improvement efforts. A self-administered survey assessed the perceptions of board members, C-suite executives, and clinical managers regarding quality activities and structures. This instrument, the Hospital Leadership and Quality Assessment Tool (HLQAT), includes 13 domains in six conceptual areas that we believe are major organizational drivers of quality and safety: (1) commitment of senior leaders, (2) a vision of exemplary quality, (3) a supportive culture, (4) accountable leadership, (5) appropriate organizational structures, and (6) adaptive capability. HLQAT survey results from a convenience sample of more than 300 hospitals were linked to performance on the Centers for Medicare & Medicaid Services (CMS) Core Measures. The results show significantly different perceptions between the groups. Higher HLQAT scores for each respondent group were associated with better hospital performance on the CMS Core Measures. There is no magic bullet--no one domain dominates. Leaders in higher-performing hospitals appear to be more effective at conveying their vision of quality care and creating a culture that supports an expectation that staff and leadership will work across traditional boundaries to improve quality.

The interviews with board members at 10 high-performing community health systems revealed many other factors that, in the opinions of some, have contributed to their system's strong operating performance; for example, prudent investments in facilities and services, new technology and strategic mistakes by competitors. On the whole, however, the trustees perceived the six factors outlined above as being most influential in their organizations' successful performance in recent years. The table on Page 21 provides a summary of the trustees' views. Numerous factors contribute in varying degrees to organizational performance. Board leaders and CEOs should assess their organization and, as objectively as possible, identify those which are truly pivotal in determining its operating performance. Allocating proper attention and resources to them and monitoring the results on an on-going basis are among the main responsibilities of governing boards in today's challenging health care environment.

The transformation of healthcare from a relatively sheltered sector of the economy into one characterized by market competition and volatility has tested the values, abilities, and leadership strategies of healthcare executives. Changes in the scale and complexity of healthcare organizations and in provider reimbursement impose demands on executives that bear little resemblance to those of the past. In light of these challenges, health management programs are reassessing their responsibilities and capacities in the preparation of MHA graduates. Unfortunately, there is a lack of consensus on how students should be trained, advised, and mentored for leadership responsibilities. In our view, MHA programs can begin to address this problem through support of a balanced normative model for leadership training whereby classroom immersion in academic subjects is complemented by exposure to practice and experience. This model must be value-oriented, balancing business imperatives with traditional service ideals, and reality-oriented, balancing the teaching methods of theory and practice. In our view, MHA programs can begin to adapt to this model though student selection, curriculum reform, and involvement by practitioners and alumni.

This analysis explores the role of the private sector relative to all health spending among Organization for Economic Cooperation and Development (OECD) countries. Bi-variate regression was employed for 31 countries using current data. It was found that the share of GDP allocated to health varies among countries, ranging from 5 percent in Turkey to 14 percent in the United States. Variation in per capita income explains much of this difference but other factors are important too. One appears to be the role of the private sector in financing health expenditures. Our analysis concludes that concern about rising health sector costs should be placed in a larger context: rising health care costs may be justified if benefits are large enough and cover the opportunity costs of alternative uses of resources.

Health officials have promoted case management as a promising intervention in substance abuse treatment (Ridgely & Willenbring, 1992). The relationship between organizational mission combined with case management and different types of outcomes has not been explored in studies, but they are worth noting and exploring further. This study, which is part of a larger clinical trial, examined the 3-, 6-, and 12-month effectiveness of case management in a residential setting for individuals treated for substance abuse. Clients who agreed to participate were randomly assigned to one of four study groups. The groups received face-to-face case management and one telecommunication case management, while the fourth was the control group. Results from the analysis revealed only modest support for the effectiveness of case management as a supplement to traditional treatment. The face-to-face case-managed groups achieved improvements on the legal, employment, and psychiatric domains exceeding that achieved by the control group. Because of the short-term follow-up of the study, conclusive evidence of the effects of case management could not be drawn. This study is a valuable stepping stone, however, to further research in the field and as an aid to policymakers who are interested in knowing more about the effects of case management.

Crossing the Quality Chasm, the Institute of Medicine's recently issued report on the quality of health care in America, is a call to arms for the urgent redesign of the U.S. health care system. The big question confronting health care organizations is how to mount new strategies that will enhance organizational effectiveness and reduce system failures as well as individual errors. Redesign implies organizational restructuring and engineering as well as serious steps in organizational development, with the emphasis on leadership enhancement strategies focused on performance excellence. This article addresses the state of the leadership literature and concludes that massive new investments will have to be made to tackle the issues of leadership training and accountability.

Healthcare spending in the United States has risen steadily throughout the post-World War II period as the American healthcare system has been transformed from cottage industry to big business. The increasing rate of social investment in healthcare also transformed America's major teaching hospitals. As a case in point, the University of Iowa Hospitals and Clinics saw annual operating revenues rise from $1 million in 1945 to more than $350 million in 1995, which was accompanied by an extraordinary expansion in its physical facilities and in its multifaceted operations. In the 1970s and even more so in the 1980s, however, the unceasing climb in healthcare spending fueled concern among policy experts, politicians, employers, and insurers alike. In turn, the search for effective cost controls led to the current managed care revolution. While the end of that revolution is not yet in sight, managed care has, it appears, effected significant cost savings, but at no small cost to America's major teaching hospitals and their social missions of teaching, research, and patient care. Whether those missions can survive--and, if so, in what form--in a healthcare system dominated by the managed care ethos is an increasingly important concern.

A study of 11 Academic Health Center Teaching Hospitals (ATHs) in 11 states found that cost reduction programs, internal reorganizations, reengineering, benchmarking, and broadened entrepreneurial activity were prominent among the strategic initiatives reported in dealing with an increasingly turbulent environment. Although none of the ATHs had experienced negative net margins, we conclude that today's competitive healthcare system requires ATHs be reimbursed separately for their educational and other societally related costs to assist them in competing on a level playing fields.

Efficiency has different connotations and denotations in management, organizational behavior, and economics. This article explores different economic and organizational orientations that have given rise to alternative definitions with the hope that better understanding of these perspectives will improve terminology and theory building.

Background: The total expense associated with acute myocardial infarction in the United States is substantial because of the combination of high volume and high cost per case. The aim of this study was to identify potential cost-saving strategies for the management of acute myocardial infarction., Methods: Information was gathered through professional interviews combined with an extensive literature review., Results: Numerous opportunities for cost savings were identified and classified into six categories: pharmaceuticals, changing the work within steps, corporate philosophy and clinical decision making, continuous physician education and involvement, preventive measures and systems of care, and additional resources., Conclusions: Although there are many possible areas healthcare providers could consider for cost saving in acute myocardial infarction, the situation at each site will need to be considered carefully before areas are selected. It is of vital importance that the quality of care not be compromised in the effort to reduce cost.

The suggestion that health services research is now on the threshold of a new era of importance is a commonplace theme in selected forums. Concern over escalating costs and quality assurance in the health care industry have inspired government, business, insurers, and health care organizations to search for answers in health services research. Those who expect a new era of assessment and accountability will be disappointed, however, if certain key conditions, such as financial resources, multidisciplinary cooperation, significant new training programs, and unified action on national and state public interest research agendas, are not satisfied.

While the expression "battle between the sexes" may be a cliche, the question being asked in business and healthcare management circles focuses on who is rising to the top of the management hierarchy--the male or the female executive. Previous research has shown a smaller percentage of women than men make it to the senior levels of management in business.

To make ethical decisions, people must be able to assign priorities to competing values. Although health professionals are expected to assign the highest priority to the value of a healthy citizenry, in this period of economic constraint, creating and reinforcing that value is problematic for many health care managers. Their dominant premise--financial survival--conflicts with the basic premise of most physicians and nurses--service to the client. Despite this problem, leaders, now more than ever, must take responsibility for a reexamination of the purpose of health care. If they do not, a new round of government regulation will be initiated to protect patient groups that may be neglected, particularly the indigent, the elderly, and the chronically ill. Training for this responsibility may be accomplished through a humanities component in undergraduate and graduate foundation courses, continuing education workshops and conferences, and leadership task forces that address short-term institutional goals and long-term national objectives.

Advocacy, a much-prized function of health care professionals, is also a largely unexamined concept. A careful review of physician advocacy reveals and ever-growing number of constraints, such as institutional and governmental cost-control policies, that serve to weaken its credibility. These complications, however, present and opportunity for recasting the carte blanche individualism of traditional advocacy along more socially responsible lines. In our view, the lines of meta-advocacy constitute a suitable moral end for policy formulation.

The dramatically changing environment of the health care executive prompted the current survey of graduate students in health administration. The survey examined the types of attitudes and values that may influence students' future leadership style and ethical decision making. A self-administered questionnaire was designed to provide descriptive information as well as to allow comparisons with recent surveys of practitioners and peers and with other research. Respondents to the survey, conducted in the fall of 1986, included nearly half of the full-time students in 56 participating AUPHA graduate programs and one-quarter of the part-time students (N = 1,764). Students' characteristics such as age, sex, religious preference, work experience, and career aspirations were assessed in relation to their social philosophy on health issues, instrumental and terminal values, attitudes toward achievement, and degree of idealism versus relativism in moral reasoning. The typical student was a twenty-seven-year-old white female with a stated religious preference who expected in ten years to be associated with a multi-institutional system or consulting firm. Her social philosophy showed concern for the rising cost of health care on the consumer and an emphasis on self-help. Self-respect and honesty are her highest values; her ethical ideology had components of high idealism and relativism, which is indicative of a situational decision-making style. Work orientation and mastery were both above average sources of achievement motivation for her, whereas competitiveness was about average. When group differences in attitudes and values were evaluated, however, sex was the highest predictor, followed by age, expectation of becoming a CEO, and self-assessed potential for success. Although there was substantial agreement between students' and practitioners' attitudes and values, some differences were found. Implications for future research are discussed, as well as issues relating to education for health administrators.