Health Services Management Research recent issues

A revised approach to performance measurement for health-care estates

May, D., Price, I. — Thu, 29 Oct 2009 17:09:29 PDT

The purpose of the research was to show how lean asset thinking can be applied to UK health-care facilities using different measures to compare the estates contribution to the business of health-care providers. The challenge to conventional wisdom matches that posed by ‘Lean Production’ to ‘Mass Manufacturing’. Data envelope analysis examined the income generated and patient-occupied area as outputs from the gross area of a NHS Trust's estate. The approach yielded strategic comparisons that conventional facilities management measures of cost per square metre hide. The annual cost of an excess estate is conservatively estimated at £600,000,000 (in England alone). Further research to understand the causes of the excess is needed. Meanwhile the research illustrates the power of an alternative way of assessing facilities performance. The authors are not aware of the lean asset perspective previously being applied to health-care facilities. The research shows the underlying fallacy of relying on cost per square metre as the primary measure of asset performance. The results and discussion will be particularly useful to senior estates and facilities managers wishing to use new measures to define strategic estates targets.

Everybody's business: from policy to lived practice - the benefits of embedding specialist mental health workers in physical health-care systems

Read, J., Andrews, T. — Thu, 29 Oct 2009 17:09:30 PDT

As Britain's population ages, health- and social-care systems face the challenge of continuing to provide high-quality care in the face of increased demand on services. Government policy has proposed meeting this challenge through integrated partnership working to enable people with complex, multiple needs to receive timely care closer to home. Co-morbid mental health needs, including dementia, are common in people with physical health issues, and must be addressed appropriately if systems are to provide the best possible all-round patient care. This paper describes how two senior clinical psychologists have developed an embedded living mental health resource within physical health care, and demonstrates how this has directly and positively impacted on both service performance indicators and patient experience.

An analysis of the factors influencing networkability in the health-care sector

Mettler, T., Rohner, P. — Thu, 29 Oct 2009 17:09:30 PDT

In most industries of economy, the production structures evolved into activities characterized by a high division of labour between the business partners combined with specialization, the standardization of service components and extensive networking. In the health-care sector, the first signs of a similar development are beginning to crystallize. As a consequence, networkability, the ability to link up with other players on the basis of commonly agreed standards for the joint provisioning of patient-centred and cost-efficient health services will emerge to a key concept for future health service delivery. As not only technical but mainly organizational and behavioural issues are actually determining networkability of health-care organizations, a holistic model for analysis is needed. In this paper, the main variables leading to an increase in this networkability are identified and compiled into a comprehensible procedure model for health-care practitioners.

Using mixed methods to identify factors influencing patient flow

Van Vaerenbergh, C. — Thu, 29 Oct 2009 17:09:30 PDT

An effective method of identifying operational factors that influence patient flow can potentially lead to improvements and thus have huge benefits on the efficiency of hospital departments. This paper presents a new inductive mixed-method approach to identify operational factors that influence patient flow through an accident and emergency (A&E) department. Preliminary explorative observations were conducted, followed by semi-structured interviews with key stakeholders. A questionnaire survey of all medical, nursing, porter and clerical staff was then conducted. The observations provided factors for further exploration: skill-mix, long working hours, equipment availability, lack of orientation programmes, inefficient IT use and issues regarding communication structures. Interviewees highlighted several factors, including availability of medical supervision and senior nursing staff, nursing documentation issues, lack of morale due to overcrowding, personality differences and factors relating to the department layout. The questionnaire respondents strongly supported the importance of the previously identified factors. This paper demonstrates an effective mixed-method approach that can be replicated by other health-care managers to identify factors influencing patient flow. Further benefits include increased volume and quality of data, increased staff awareness for the influence of internal factors on patient flow and enhancing the evidence base for future decision making when prioritizing A&E projects.

Use of card sort methodology in the testing of a clinical leadership competencies model

Jahrami, H., Marnoch, G., Gray, A. M. — Thu, 29 Oct 2009 17:09:30 PDT

The purpose of this paper is to examine the utility of a qualitative ‘card sort’ research tool – when it is merged with traditional quantitative data gathering methods – to add to our understanding about the nature of competency-based approaches to leadership studies. The study demonstrates how a qualitative technique (card sort) was used for the task of testing a clinical leadership competencies model. All the steps in the card sort methodology are described through its application to the research problem. The paper concludes that card sort has considerable use in adding to the validity of research into the competency approach to leadership. The study reports only one single case. Therefore, the technique must be repeated to secure its validation as a testing technique. The card sort method is proven to be a viable tool to ascertain the individual subjects perceptions regarding competencies. The methodology is described in sufficient detail so as to enable its replication and application by professionals and academic researchers alike. Both groups will find this methodology useful and interesting. The paper seeks to improve upon existing methods for studying leadership competencies. By addressing the limitations of different methods, and also by merging different independent approaches, this project provides an innovative integrated knowledge that can be of significant value.

Performance evaluation of ambulatory surgery centres: an efficiency approach

Iyengar, R. N, Ozcan, Y. A — Thu, 29 Oct 2009 17:09:30 PDT

This paper evaluates the performance of 198 ambulatory surgery centres (ASCs) operating in the State of Pennsylvania during the fiscal year 2006. Performance is assessed from technical efficiency view using data envelopment analysis (DEA). Multi-input/output model included two inputs: number of operating rooms and labour, and patient surgical visits differentiated by age groups: 0–17, 18–64, 65+ as three outputs. Input oriented models were employed to assess various DEA efficiency models. Results show that about 48 (24%) of ASCs are efficient with a mean efficiency score of 0.60. The results also indicate that appropriate utilization of operating rooms and labour inputs are the main determinants of ASC efficiency.

Patient satisfaction questionnaire and quality achievement in hospital care: the case of a Greek public university hospital

Matis, G. K, Birbilis, T. A, Chrysou, O. I — Thu, 29 Oct 2009 17:09:30 PDT

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.

Do effective meetings determine progress in research?

Scholz, T., Koehler, C., Evans, G. R D — Thu, 29 Oct 2009 17:09:30 PDT

Progress in research is dependent on many success factors. In this review, we evaluate the importance of effective scientific meetings to achieve this progress. We focus on aspects that determine effective communication, such as length, size, interpersonal interactions, structure, and variety of meetings or conferences. Furthermore, we introduce the technique of a Syntegration^® that offers a new tool to communicate effectively among managers today. It is discussed whether this process can be a useful structure for research meetings and whether it has the potential to generate decision-making and goals within this field.

Complex leadership competency in health care: towards framing a theory of practice

Ford, R. — Fri, 24 Jul 2009 10:38:38 PDT

Many analysts characterize the health-care industry and health-care systems as complex adaptive organizations. New hybrid organizational forms are emerging that exhibit diverse relational-structural alliances between physicians, hospitals and/or insurers, over which administrators have limited control and restricted ability to predict or direct. Meeting the challenges in leading and managing health-care systems as complex adaptive organizations calls for additional competency in what theorists determine as ‘complex leadership’. This research study presents findings on complex leadership principles that augment those competencies that health-care administration education scholars recognize and recommend as necessary for future leaders in health care to master. The findings from this study make two contributions: first, they ground complex leader theory, derived from complexity science, in empirical data; and second, the findings add to a growing body of literature investigating the underlying logics of the complex adaptive organization and the innovative ways complex leaders are developing practices and principles in leading and managing these new, emerging organizations.

Performance assessment in the maternity pathway in Tuscany region

Nuti, S., Bonini, A., Murante, A. M., Vainieri, M. — Fri, 24 Jul 2009 10:38:38 PDT

The paper describes the performance measurement system of the maternity pathway used in Tuscany by health care professionals, general managers and regional policy-makers. This system uses 19 indicators grouped in six dimensions: population's state of health; compliance with regional guidelines; efficiency and financial performance; clinical and health assessment; patient satisfaction; and employees' satisfaction. The results are represented on a spider diagram that summarizes the results on the different dimensions. The Tuscan performance measurement system of the maternity pathway has been used to identify best practice within, and their adoption throughout, the Tuscan public health care system.

The individual and organizational commitments needed for a successful diabetes care community of practice

Gibson, J., Meacheam, D. — Fri, 24 Jul 2009 10:38:38 PDT

Through a qualitative case study of a regional diabetes care programme in New South Wales, Australia, this article examines the phenomenon of communities of practice (CoPs) within organizations, with a specific focus on identifying the commitments required from both individuals and organizations in order to produce a successful CoP. The CoP literature suggests that ‘commitment’ is essential, yet the exact nature of this ‘commitment’ has not been identified. This study aims to discover what these commitments are. From the research data, key individual and organizational commitments are identified. The individual commitments needed are (in rank order of significance): a personal commitment to the aim of the CoP; a commitment to knowledge-sharing with others; a commitment to knowledge-seeking from others; effective management of personal relationships with others in the CoP; and understanding of the roles of other members. At the organizational level, the commitments needed are a good fit between the purposes of the CoP and the aims of the organizations employing the CoP members, a commitment to research regarding the CoP's activities, sufficient funding of the work of CoP members, continuing practical and political support to the CoP and facilitation of innovation within the CoP. Recommendations are made relating to the practical significance of the findings of the study. The implications of the findings are assessed relative to other health-service CoPs.

Improving patient safety incident reporting systems by focusing upon feedback - lessons from English and Welsh trusts

Wallace, L. M, Spurgeon, P., Benn, J., Koutantji, M., Vincent, C. — Fri, 24 Jul 2009 10:38:38 PDT

This paper describes practical implications and learning from a multi-method study of feedback from patient safety incident reporting systems. The study was performed using the Safety Action and Information Feedback from Incident Reporting model, a model of the requirements of the feedback element of a patient safety incident reporting and learning system, derived from a scoping review of research and expert advice from world leaders in safety in high-risk industries. We present the key findings of the studies conducted in the National Health Services (NHS) trusts in England and Wales in 2006. These were a survey completed by risk managers for 351 trusts in England and Wales, three case studies including interviews with staff concerning an example of good practice feedback and an audit of 90 trusts clinical risk staff newsletters. We draw on an Expert Workshop that included 71 experts from the NHS, from regulatory bodies in health care, Royal Colleges, Health and Safety Executive and safety agencies in health care and high-risk industries (commercial aviation, rail and maritime industries). We draw recommendations of enduring relevance to the UK NHS that can be used by trust staff to improve their systems. The recommendations will be of relevance in general terms to health services worldwide.

Chronic disease management and the home-care alternative in Ontario, Canada

Tsasis, P. — Fri, 24 Jul 2009 10:38:38 PDT

The pressure on our health-care system to deliver efficient, quality and cost-effective care is increasing. The debate on its sustainability is also expanding. These challenges can be managed with revisions to our health-care policy frameworks governing how and what public health-care services are delivered. Chronic disease management and home care can together ease many of the present and future pressures facing the health-care system. However, the current level of investment and the present policy are not effectively supporting movement in this direction. Updating the Canada Health Act to reflect the realities of our health-care system, and developing policies to support the areas of interdisciplinary teamwork and system integration are needed to facilitate chronic disease management and home care in Canada. This article lays out the challenges, highlights the impending issues and suggests a framework for moving forward.

Strategic information technology alliances for effective health-care supply chain management

Shih, S. C, Rivers, P. A, Hsu, H Y S. — Fri, 24 Jul 2009 10:38:38 PDT

To gain and sustain competitive advantage, health-care providers have to continuously review and renovate their operational and information technology (IT) strategies through collaborative and cooperative endeavour with their supply chain channel members. This paper explores new ways of enhancing a health-care organization's responsiveness to changes and increasing its competitiveness through implementing strategic information technology alliances among channel members in a health-care supply chain network. An overview of issues and problems (e.g. bullwhip effect, negative externalities and free-riding phenomenon in multichannel supply chains) presented in the health-care supply chains is first delineated. This paper further goes over the issues of health-care supply chain coordination and integration for strategic IT alliances, followed by the discussion of the spillover effect of IT investments.

A number of viable IT practices (such as information sharing and Internet-enabled supply chain portal) for effective health-care supply chain collaboration and coordination are then examined in this research. Finally, the paper discusses how strategic IT alliances can help improve the effectiveness of health-care supply chain management.

Benchmarking nursing home performance at the state level

Lenard, M. L, Shimshak, D. G — Tue, 28 Apr 2009 11:03:20 PDT

This paper reports the results of a state-level comparison of the performance of nursing homes. The results were obtained by applying data envelopment analysis (DEA) to data (obtained from OSCAR, the online survey, certification and reporting database [2004]) for all the skilled nursing facilities in each of the 50 states and the District of Columbia. DEA produces an efficiency score for each state that can serve as a single comprehensive measure of its overall performance. However, two DEA models were used in the analysis reported here so that each state could be given two efficiency scores, one for each of the two aspects of their performance – quality efficiency and operating efficiency. Eleven states were identified as being 100% efficient for both quality and operating efficiency of their nursing homes. For the remaining states (i.e. those having lower scores for either quality efficiency or operating efficiency or both), DEA results include, in addition to the efficiency score, performance goals and a benchmark set of other states that could be used as models of ‘best practice’.

The influence of facility ownership structure on individual responding to stress: a multilevel model

Yeh, S.-C. J., Huang, C.-H., Chou, H.-C., Wan, T. T H — Tue, 28 Apr 2009 11:03:20 PDT

Few studies have investigated the effect of health-care facility ownership on the relationship between patient stressors and coping strategies. The purpose of this study was to investigate whether haemodialysis (HD) patient stressors and coping strategies differ by type of health-care facility ownership, and whether such ownership has a cross-level moderating effect between stressors and coping strategies. We used the Haemodialysis Stressor Scale and the Jalowiec Coping Scale; primary data were collected by interviewing 2642 HD patients 15 years or older on dialysis for at least three months from 27 HD centres. One-way analysis of variance and hierarchical linear modelling were used to attain the research purposes. HD patients from religious-based hospitals had higher stress related to their physical symptoms, dependency on medical staff, role ambiguity and blood vessel problems than those differently owned facilities. Patients in veterans and army (VA) hospitals had higher stress related to food and fluid restriction and dependency on medical staff than private centres. Patients in religious-based hospitals had significantly higher coping scores, followed by VA and private HD centres. Religion-based ownership might serve as a cross-level moderator for patients perceiving role ambiguity stress and using problem-oriented, support seeking and isolated thought-coping strategies.

Systems thinking, complexity and managerial decision-making: an analytical review

Cramp, D G, Carson, E R — Tue, 28 Apr 2009 11:03:20 PDT

One feature that characterizes the organization and delivery of health care is its inherent complexity. All too often, with so much information and so many activities involved, it is difficult for decision-makers to determine in an objective fashion an appropriate course of action. It would appear that a holistic rather than a reductionist approach would be advantageous. The aim of this paper is to review how formal systems thinking can aid decision-making in complex situations. Consideration is given as to how the use of a number of systems modelling methodologies can help in gaining an understanding of a complex decision situation. This in turn can enhance the possibility of a decision being made in a more rational, explicit and transparent fashion. The arguments and approaches are illustrated using examples taken from the public health arena.

A conceptual framework for selecting the most appropriate variables for measuring hospital efficiency with a focus on Iranian public hospitals

Afzali, H. H. A., Moss, J. R, Mahmood, M. A. — Tue, 28 Apr 2009 11:03:20 PDT

Over the past few decades, there has been an increasing interest in the measurement of hospital efficiency in developing countries and in Iran. While the choice of measurement methods in hospital efficiency assessment has been widely argued in the literature, few authors have offered a framework to specify variables that reflect different hospital functions, the quality of the process of care and the effectiveness of hospital services. However, without the knowledge of hospital objectives and all relevant functions, efficiency studies run the risk of making biased comparisons, particularly against hospitals that provide higher quality services requiring the use of more resources. Undertaking an in-depth investigation regarding the multi-product nature of hospitals, various hospital functions and the values of various stakeholders (patient, staff and community) with a focus on the Iranian public hospitals, this study has proposed a conceptual framework to select the most appropriate variables for measuring hospital efficiency using frontier-based techniques. This paper contributes to hospital efficiency studies by proposing a conceptual framework and incorporating a broader set of variables in Iran. This can enhance the validity of hospital efficiency studies using frontier-based methods in developing countries.

Innovations in coaching and mentoring: implications for nurse leadership development

Fielden, S. L, Davidson, M. J, Sutherland, V. J — Tue, 28 Apr 2009 11:03:20 PDT

This longitudinal study sought to examine ways in which coaching and mentoring relationships impact on the professional development of nurses in terms of career and leadership behaviours, and evaluating the differences and similarities between those coaching and mentoring relationships.

According to the UK government, leadership in nursing is essential to the improvement of service delivery, and the development and training of all nurses is vital in achieving effective change. A coaching and mentoring programme was used to explore the comparative advantages of these two approaches for the leadership development of nurses in acute, primary care and mental health settings.

A longitudinal in-depth study was conducted to measure differences and similarities between the mentoring and coaching process as a result of a six-month coaching/mentoring programme. Five nurses from six UK Health Care Trusts were allocated to a coaching group (n = 15) or a mentoring group (n = 15), these were coached or mentored by a member of the senior directorate from their own Trust. Qualitative and quantitative data were collected at three time points (T1 = baseline, T2 = 4 months and T3 = 9 months) using semi-structured interviews and questionnaires.

While mentoring was perceived to be ‘support’ and coaching was described as ‘action’, descriptions of the actual process and content were quite similar. However, while both groups reported significant development in terms of career development, leadership skills and capabilities, mentees reported the highest level of development with significantly higher scores in eight areas of leadership and management and in three areas of career impact. Implications for nurses and health services are discussed.

Operating environment and USA nursing homes' participation in the subacute care market: a longitudinal analysis

Weech-Maldonado, R., Qaseem, A., Mkanta, W. — Fri, 30 Jan 2009 10:55:46 PST

We examined the impact of environmental factors on USA nursing homes' participation in the subacute care market. Findings suggest that the Balanced Budget Act of 1997 did not have a significant impact in the participation of nursing homes in the subacute care market from 1998 to 2000. However, there was a declining trend in the participation of nursing homes in the subacute care market after the implementation of Medicare prospective payment system (PPS). Furthermore, nursing homes with a higher proportion of Medicare residents were more likely to exit the subacute care market after PPS. Results also suggest that nursing homes have responded strategically to the environmental demand for subacute care services. Nursing homes located in markets with higher Medicare managed care penetration were more likely to offer subacute care services. Environmental munificence was also an important predictor of nursing home innovation into subacute care. Nursing homes in states with higher Medicaid reimbursement and those in less competitive markets were more likely to participate in the subacute care market.

What do we know? Limitations of the two methods most commonly used to estimate the length of the prospective wait

Armstrong, P. W — Fri, 30 Jan 2009 10:55:46 PST

Health service researchers, policy analysts and other commentators have overlooked the limitations of existing approaches to the estimation of waiting times. If urgent cases are given priority, there are no instances when census-based data can supply accurate estimates of the length of the prospective wait. But there are three occasions when event-based data supply accurate estimates of the prospective wait of those who chose to enrol and we can predict the direction of error when the relevant conditions are violated if we know whether the list was open or closed, and whether it grew in size or shrank. Without this additional information, we cannot determine whether the changes we observe over time or the differences we see between one list and the next are spurious or not. The period life-table provides a timely and bias-free alternative to the existing cross-sectional approaches for a modest increase in the complexity of calculation.

The development of an ongoing monitoring and evaluation system in a NORC service organization

Cohen-Mansfield, J., Frank, J. K — Fri, 30 Jan 2009 10:55:46 PST

The objective of this study was to describe the development, utilization and utility of an ongoing evaluation of a system of coordinated services to persons living in two naturally occurring retirement communities (NORCs).

The evaluation system includes service provision, service utilization and client satisfaction. It identifies trends in provided services and determines how services are utilized. A continuous monitoring system for reporting and quality improvement was developed with the four service agencies associated with the service provision system. The monthly data from each agency are compiled and distributed in the form of a report.

The evaluation project was successful in tailoring the reporting system to each agency. Multiple issues arose with staff compliance in utilization of the system, but, overall, the system evaluation presents detailed feedback on the services provided and helps with continuing development, testing of new delivery models, planning, maximizing resource utilization, customer service, and attaining and sustaining funding.

A system evaluation of an organization that provides services to a community is vital to optimizing frequency and quality of services. There are many ways to implement system evaluations. However, the use of electronic-based records increases the likelihood of maintaining and utilizing the system.

Travel-related costs of population dispersion in the provision of domiciliary care to the elderly: a case study in English Local Authorities

Hindle, T., Hindle, G., Spollen, M. — Fri, 30 Jan 2009 10:55:46 PST

The aim of this research has been to make a contribution to deliberations concerning the relative costs of provision of domiciliary services for the elderly in local authorities in England and the implications for funding. The main services considered have been day-centre services and home-care services, and the particular cost areas investigated have been travel-related costs as associated with distances travelled by day-centre vehicles and care workers and with worker travelling hours. These costs are influenced by the population settlement and dispersion characteristics of the areas served and funding mechanisms are needed (and are in place) to compensate service providers. However, current mechanisms have been widely criticized and the research reported here reaches conclusions about whether such criticisms are justified and how improvements might be brought about. The methods used have involved detailed operational modelling of the selected services in a sample of local authority areas and the generalization of the findings to England as a whole.

Using the balanced scorecard in the development of community partnerships

Tsasis, P., Owen, S. M — Fri, 30 Jan 2009 10:55:46 PST

The benefits of community partnerships have been well established in the health service literature. However, measuring these benefits and associated outcomes is relatively new. This paper presents an innovative initiative in the application of a balanced scorecard framework for measuring and monitoring partnership activity at the community level, while adopting principles of evidence-based practice to the partnership process. In addition, it serves as an excellent example of how organizations can apply scorecard methodology to move away from relationship-based partnerships and into new collaborations of which they can select – using a formal skill and competency assessment for partnership success.

Do hospitals practice cream skimming?

Friesner, D. L, Rosenman, R. — Fri, 30 Jan 2009 10:55:46 PST

‘Cream skimming’ refers to choosing patients for some characteristic(s) other than their need for care, which enhances the profitability or reputation of the provider. Under capitation or other fixed payment schemes, this often means choosing less ill patients. We present a new methodology to measure cream skimming by hospitals. Our approach also provides a measure of a hospital's gain in productive efficiency by caring for patients with lower illness severity. Using a panel of Washington state hospitals, we find evidence that hospitals do practice cream skimming. However, we find little evidence to suggest that cream skimming varies by hospital size, profit status or time.