Focus as emphasis: Conceptual and performance implications for hospitals

Focus in hospitals has been heralded as the next frontier in improving its efficiency and efficacy (Herzlinger, 2004). However, there is scarce empirical work examining its effects in this setting. Focus in hospitals can take several different forms, ranging from standalone specialty centers to a hospital that chooses to emphasize in some operational way a particular specialty while still offering a full range of services. Although standalone facilities can be found in many locations, the vast majority of hospitals must follow the latter route to achieve focus. Current conceptualizations and measures of focus struggle to capture this construct in a way that does not assume a narrowing of range of offerings. In contrast to the traditional view of focus as narrowing, in this paper, we address the perspective of focus as emphasis. We select cardiology as the specialty and use secondary data for more than 264,000 patients in New York State to examine the relationship between focus as emphasis and hospital cost performance. Our results support the notion that such focus is associated with lower costs. Moreover, our results also show that focus in hospitals can be operationalized as a disproportionate emphasis on one line of service, without necessarily narrowing the overall range of services provided.     

Process quality improvement: An examination of general vs. outcome-specific climate and practices in hospitals

Despite numerous efforts to foster quality improvement in healthcare, much of the extant data and research indicate that substantial shortcomings in the delivery of effective and reliable care remain. This research examines both general and outcome-specific operations management efforts and their impact on delivering quality healthcare. We empirically test a conceptual framework of safety culture that accounts for the use of general quality practices as well as outcome-specific approaches in light of the general and more focused climates in which those practices are embedded. We utilize structural equation modeling to analyze a unique pairing of primary data from a survey of quality improvement directors and chief nursing officers at 272 hospitals across the U.S. with secondary data on process of care performance publicly reported by the federal government's Center for Medicare and Medicaid Services (CMS). General safety climate and quality practices are found to establish an environment in which outcome-specific efforts enable process quality improvement. A split-group SEM analysis highlights significant differences in managing healthcare safety outcomes through climate and practices. In particular, the employment of practices focused on the specific outcome goals is found to relate to higher quality of patient care in smaller hospitals. In contrast, the development of a climate focused on specific outcome goals is found to relate to higher quality of patient care in larger hospitals. These findings suggest alternative approaches for small and large hospitals in the critical effort to improve patient safety and reduce healthcare costs.     

Technical and organisational aspects in enterprise resource planning systems implementation: lessons from a Spanish public hospital

Public resources should always be managed efficiently, more so in times of crisis. Due to the specific characteristics of the healthcare sector, there is a need for special attention, especially in regards to hospitals. Administrators need useful tools to be able to efficiently manage available resources, such as enterprise resource planning (ERP) systems. Therefore, an analysis of the effects of their implementation and use in hospitals is valuable. This study has two purposes. One is to analyse the role ERP systems play in aiding the integration of hospital data, with focus on user satisfaction as well as possible resistance to change. The other purpose is to analyse the effects of implanting and using ERP systems in the hospital environment and identifying how certain variables influence the process, especially the existence of different organisational cultures. Results indicate that clinical information has become notably more integrated, despite the lack of flow in the economic–financial area. The heterogeneous nature of the different groups, clinical (Medical, Nursing) and non-clinical (Economic–Financial, Accounting), had a negative influence on the implementation process, and limited the integration of information as well as the system's performance.     

Lost in translation: exploring the link between HRM and performance in healthcare

Using data collected in 2004 from 132 Victorian (Australia) public healthcare providers, comprising metropolitan and regional hospital networks, rural hospitals and community health centres, we investigated the perceptions of HRM from the experiences of chief executive officers, HR directors and other senior managers. We found some evidence that managers in healthcare organisations reported different perceptions of strategic HRM and a limited focus on collection and linking of HR performance data with organisational performance management processes. Using multiple moderator regression and multivariate analysis of variance, significant differences were found in perceptions of strategic HRM and HR priorities between chief executive officers, HR directors and other senior managers in the large organisations. This suggested that the strategic human management paradigm is ‘lost in translation’, particularly in large organisations, and consequently opportunities to understand and develop the link between people management practices and improved organisational outcomes may be missed. There is some support for the relationship between strategic HRM and improved organisational outcomes. Implications of these findings are drawn for managerial practice.     

Ten years after: Interference of hospital slack in process performance benefits of quality practices

We investigate the long-term relationship between an organization's quality management practices and process-level performance. Further, we examine whether availability of organizational slack over the study interval interferes with the relationship between quality practices and process performance. Organizational slack consists of the available and accessible resources in an organization; we focus here on unabsorbed slack in the form of financial resources. We investigate the quality practices of U.S. general acute care hospitals, measured by their depth of implementation of practices characterizing a total quality management system, and use them to predict process performance related to four medical conditions. Analysis reveals differing effects that are dependent on hospital slack conditions. In hospitals with high slack, quality practices significantly predict three of four studied process performance measures. In contrast, in hospitals with low slack, quality practices predict only one of the four process performance measures, while other factors outweigh the effects of quality practices. This study lends support to management taking a long-term perspective related to implementation of quality management systems, and highlights the relevance of slack conditions in garnering the benefits of such systems.     

三级医院后勤人才队伍建设的思考

在高度知识密集型的医疗行业,医院一直以来都比较重视医护人员的培养和引进,忽略了后勤人才队伍的建设,面对现代化医疗技术的快速发展,三级医院在医护人员工作量越来越大的情况下,医院要通过加快后勤人才队伍的建设,积极探索后勤人才管理机制,在人才培养、引进、激励和管理等方面进行有益的探索,为医院的可持续发展提供有力的后勤保障。     

The impact of service design and process management on clinical quality: An exploration of synergetic effects

While service design and process management have received research attention in the past, there is limited empirical work examining both factors in the hospital setting. Through operationalizing focus as a service design approach and quality improvement (QI) initiatives as process management efforts, we hypothesize that focus and QI initiatives affect clinical quality both individually and collectively. Utilizing heart attack procedures as the study context, we examine a set of hypotheses based on a panel dataset consisted of 201 hospitals from 2005 to 2011 in the state of Florida. After accounting for potential lag effects and endogeneity biases, we find empirical support to the proposed hypotheses.     

Evaluation of efficiency in Colombian hospitals: An analysis for the post-reform period

In this study we analyze the performance of 602 level 1 Colombian hospitals for the period 2009–2013. The analysis is carried out from both static and temporal perspectives in order to evaluate the evolution of total factor productivity (change in hospital performance) and its components throughout the period. The study also explores a question relevant not only to the Colombian health system, but to many others around the world, of whether primary care centers excessively refer patients to high-level hospitals, thereby negatively affecting the quality, efficiency, and effectiveness of all healthcare service provision. The results demonstrated that adjusted production (service provision) and levels of quality and referrals to higher-level hospitals could be improved, on average, by 44%. This increase in health service provision levels and their quality can be achieved by reducing personnel expenditure (by an average of 22%), expenditure on medicines (by 20%), and purchasing expenses (by 11%). The temporal analysis shows that total factor productivity (hospital performance change) worsened by 1% during the period, mainly due to the technological backlash experienced despite a slightly positive evolution in efficiency.     

Improving operational performance by influencing shopfloor behavior via performance management practices

It is generally believed that companies applying performance management practices outperform those that do not measure and manage their performance. Studies examining the link between performance management and performance improvement implicitly assume that performance management affects behavior of individuals in an organization, which then facilitates the achievement of organizational goals. This study takes a step towards understanding this implicit assumption. We investigate how performance management practices relate to improvement in performance by influencing behavior of individuals. We focus on operational performance management, i.e. the definition and use of performance measures on the shopfloor in production and distribution. We use a survey among 102 companies to identify the relations between performance management practices, shopfloor behavior and improvement in performance. We identified three independent clusters of operator behavior that positively correlate with performance improvement: “Understanding”, “Motivation” and “Focus on Improvement”. We show that 17 out of the 20 performance management practices found in literature have a significant and positive relation with one or more clusters of operator behavior. We furthermore found that there is a positive correlation between the number of performance management practices applied and performance improvement, suggesting that it is not only which practices are applied but also how many. Recommendations emerging from this study enable managers to identify which behavioral changes are desired to improve performance and to select those performance management practices that positively influence the desired behavior.     

Effects of healthcare quality and reimbursement rate in a hospital association

Tackling the mismatch between the supply of and demand for care service is an especially important issue among many healthcare providers and regulators. To entice patient demand distribution to become more equilibrated among different regions, some countries' governments have proposed to establish a hospital association with different levels of hospitals to implement patient mobility. However, the sustainable operation and management of the hospital association have not been formally analyzed. In this paper, we develop a Salop model to analyze the strategic behavior of patient welfare and hospital utility maximizations in a hospital association comprised of three hospitals in different income regions. For the former objective, we find that the higher quality provisions may harm patient welfare, and especially there are unique quality thresholds of the hospitals such that the higher quality provisions lead to higher patient welfare only when the quality provisions exceed the thresholds. For the latter objective, we capture the optimal equilibrium quality provisions of the overall hospital association. We consider both the case when the taxation rates are regulated (TRR) and exogenous to the hospitals and the case when taxation rates are adjusted (TRA) and constrained by hospital reimbursement rates. Under the TRA case, we find that a higher reimbursement rate of the local hospital causes a higher and lower quality threshold of the hospital in the local and neighboring regions, respectively; and we also show that with the utility maximization objective, the reimbursement rate's impact depends on regulator's altruism towards patient welfare. For a relatively low altruistic behavior, a TRA could improve the quality provision but lower the number of outflowing patients in the case of a high (and low) hospital's reimbursement rate in the local (and neighboring) region. When the regulator cares more about patient welfare, the findings in the quality provision and patient mobility are just contrary. Our analytical results lead to some important policy implications for facilitating the further deployment of hospital association delivery in the hospitals' quality provision associated with patient mobility.     

Understanding information exchange in healthcare operations: Evidence from hospitals and patients

Coordination – or the information exchange among physicians and hospital staff – is necessary for desirable patient outcomes in healthcare delivery. However, coordination is difficult because healthcare delivery processes are information intensive, complex and require interactions of hospitals with autonomous physicians working in multiple operational systems (i.e. multiple hospitals). We examine how three important variables distinctive of the healthcare operations context – use of IT for dissemination of test results (ITDR) (i.e. electronic health records systems) by physicians and hospital staff, social interaction ties among them, and physician employment – influence information exchange and patient perceptions of their care. Drawing from the literature on process inter-dependencies and coordination, vertical integration and social exchange, we develop and test research hypotheses linking ITDR, social interaction ties and physician employment to information exchange relationship, and information exchange relationship to provider–patient communication. Using a paired sample of primary survey data and secondary archival data from CMS HCAHPS for 173 hospitals in the USA, we find that increased information exchange relationship drives provider–patient communication, and increased social interaction ties drives information exchange relationship. Social interaction ties fully mediates the relationship between ITDR and information exchange relationship. Physician employment amplifies the link between ITDR and social interaction ties, but does not have an effect on the link between ITDR and information exchange. We do not find a direct relationship between ITDR, and information exchange relationship or provider–patient communication.     

The General NFP Hospital Model

Throughout the past 30 years, there has been a lot of controversy surrounding the proliferation of new forms of health care delivery organizations that challenge and compete with general NFP community hospitals. Traditionally, the health care system in the United States has been dominated by general NFP (NFP) voluntary hospitals. With the number of for‐profit general hospitals, physician‐owned specialty hospitals, and ambulatory surgical centers increasing, a question arises: “Why is the general NFP community hospital the dominant model?” In order to address this question, this paper reexamines the history of the hospital industry. By understanding how the “general NFP hospital” model emerged and dominated, we attempt to explain the current dominance of general NFP hospitals in the ever changing hospital industry in the United States.     

Analysis of different public policies through simulation to increase total social utility in a healthcare system

Public and private hospitals are seen to co-exist in several countries and they have different levels of service, waiting times and prices. Public hospitals, in general, are cheaper, but more crowded and offer lower quality service than private ones while private ones are underutilized because of the higher payments required for their services. These differences among hospitals affect patients’ choices in hospital selection and result in different levels of satisfaction in the community. Appropriate subsidy mechanisms can be developed to balance the capacity utilization of both sectors and to improve overall access to healthcare. The objective of this study is to develop an estimate of the magnitude of this improvement and differential effectiveness of various policies in achieving this improvement. For this purpose, we develop a simulation model that includes all the emergency departments of main public and private hospitals in a certain region of Turkey. We analyze the effects of different public policies on patients’ preferences regarding hospital choices and the results of these choices on social utility and public healthcare spending. Different capacity decisions, contracting and subsidy mechanisms are proposed and the optimal system parameters are determined under these mechanisms over this simulation model. After the validation and verification of the simulation model, several scenarios are designed and executed to increase social utility, decrease government expenses, improve patient satisfaction level and decrease waiting times. We compare the proposed scenarios based on multiple objective functions and present numerical results for different scenarios in this system.     

Two perspectives on multiskilling and product-market volatility

We study the effect of product-market volatility on a firm's choice between multiskilling and specialization. We construct a theoretical model that captures the tradeoff between multiskilling (which gives greater flexibility to reassign workers in production) and specialization (which provides workers with the expertise to respond to product market signals in their area of specialty). Using data from a nationally-representative cross section of British establishments, we find that greater volatility is associated with greater specialization. This result holds both inside and outside of manufacturing, but consistent with our model, it holds only in multi-product establishments and not in single-product ones.     

Child Health Corporation of America: a different perspective on materiel management

Today, based on current programs and services, CHCA is recognized as one of the leading specialty hospital alliances in the country. This is made possible by the excellent support and commitment of its shareholder hospitals. As CHCA looks toward the future, it is anticipated that it will expand its horizons with additional programs and member hospitals.     

Enhancing hospital supply chain performance: A relational view and empirical test

Improving hospital supply chain performance has become increasingly important as healthcare organizations strive to improve operational efficiency and to reduce cost. In this study, we propose a research model based on a relational view, delineating the factors that influence hospital supply chain performance: trust, knowledge exchange, IT integration between the hospital and its suppliers, and hospital–supplier integration. Testing results of the research model based on data from a sample of 117 supply chain executives from U.S. hospitals show positive direct effects: (1) from trust and from IT integration to knowledge exchange respectively; (2) from knowledge exchange and from IT integration to hospital–supplier integration respectively; and (3) from hospital–supplier integration to hospital supply chain performance. The results also show the following indirect effects: (1) the influences of knowledge exchange and IT integration on hospital supply chain performance are partially and fully mediated by hospital–supplier integration, respectively and (2) the influences of trust and IT integration on hospital–supplier integration are fully and partially mediated by knowledge exchange, respectively. In addition, the results show the following moderating effects: (1) hospital system membership moderates the relationships between IT integration and knowledge exchange and between trust and knowledge exchange; (2) hospital environmental uncertainty moderates the relationship between trust and knowledge exchange; and (3) trust moderates the relationship between knowledge exchange and hospital–supplier integration. Implications of the study findings and directions for future research are discussed.     

The adoption,character and impact of strategic human resource management: a case study of two large metropolitan Vietnamese public hospitals

In this paper the researchers set out to explore the adoption, character and impact of strategic human resource management (SHRM) in two large metropolitan Vietnamese public hospitals using a multi-level qualitative research design. Data are analyzed from 21 interviews and 5 focus groups with key players from the hospitals and government authorities. Findings show that the State controls many of the core day-to-day HR functions of public hospitals, curtailing local autonomy and management innovation. This is compacted by inadequate government funding, poor training of medical staff, and inadequate management and business skills of hospital managers. Inhibiting greater experimentation with SHRM is the fear of developing management initiatives out of sync with the State. Consequently, many managers and clinicians held negative views of the HR department and their relevance for the day-to-day management of healthcare services. Respondents reported that they perceived these factors had a negative impact on the well-being of medical staff and the quality of patient care. The paper concludes with a discussion on the necessity for continued State reforms that can enable greater autonomy of the hospitals' HRM functions and greater investment in local HR capabilities to materialize the link between SHRM, employee well-being and quality of patient care.     

Public-private partnerships in health care services: Do they outperform public hospitals regarding quality and access? Evidence from Portugal

Public-private partnerships (PPPs) are widely spread long-term arrangements between governments and strategic private partner(s). One of their objectives is to reduce the financial pressure on the public treasury with regard to new investments. PPPs have been employed within the health care sector which, in turn, carries a huge social burden. In Portugal, for instance, PPPs in health care concern bundling hospital infrastructure and clinical services management. Notwithstanding the need to ensure sustainability and efficient use of hospital resources, it is clearly compulsory to guarantee that patients receive appropriate and timely care, with maximum security, and equitable manner. Still, little or even no attention has been paid in the literature to the clinical response capacity of PPP hospitals and to the populism arguing that these entities have a lower social performance than typical public hospitals. This study uses robust benchmarking methodologies alongside recent data about Portuguese hospitals (FY2012-FY2017) to demystify this idea and to demonstrate that, actually, PPP hospitals can deliver health care services with social performance levels at least as good as public hospitals.     

The effect of management commitment to service quality on frontline employees' affective and performance outcomes: an empirical investigation of the New Zealand public healthcare sector

• Very little attention has been given to understand the antecedents of service recovery performance in a public healthcare setting. In this study, a cross-sectional survey investigates a model of service recovery performance. Frontline hospital employees completed a self-administered questionnaire on how factors characterising management commitment to service quality (MCSQ) affect their service recovery efforts. The results suggest the influence of MCSQ is mediated by frontline employees' affective commitment to their hospital. The research advances understanding of frontline service recovery performance in a public healthcare setting and the findings indicate that public healthcare managers can take actions on a number of fronts to assist progress towards the achievement of frontline service recovery excellence.

Copyright © 2006 John Wiley & Sons, Ltd.     

Efficiency analysis of emergency departments in metropolitan areas

The demand in the healthcare industry is increasing exponentially due to aging population of the world and this is leading to a rapid increase in the cost of healthcare. The emergency departments of the hospitals are the frontline of health care systems and play an additional critical role in providing an efficient and high-quality response for patients. The overcrowding at the emergency departments due to growing demand results in a situation where the demand for ED services exceeds the ability to provide care in a reasonable amount of time. This has led countries to reconsider their health policies in a way to increase their efficiency in their healthcare systems in general and in emergency departments, in particular. As in many countries, there has been a steady and significant increase in the number of patients that seek health services at the emergency departments of state hospitals of Turkey, due to the significant structural reforms in health services since 2003. While meeting this increasing demand, it is ever more important to provide these critical health services efficiently. Therefore, the efficiency of the emergency departments of seven general hospitals run by Istanbul's Beyoglu State Hospitals Association have been analyzed using categorical Data Envelopment Analysis (DEA) models. The analysis of DEA results is supported by a set of statistical methods to make it easier for the hospital administrators to interpret the analysis and draw conclusions. The analysis shows that less-equipped EDs are supported by better equipped, larger EDs, resulting in a hub-and-spoke type of structure among the EDs where “satellite” EDs serve an important referral function and thus evaluating their efficiency without taking the interoperability among these units into account would not be an accurate assessment of their performance.